Does Insurance Pay for Clinical Trials, Second Opinions and Telehealth?

I often receive questions about whether insurance will cover clinical trials, second opinions, and telehealth. I’ll break it down for you in this article.

The first thing you need to do is know your insurance! I say this a lot, but it really is your foundation of care. Knowing your insurance every step of the way in your treatment journey is important so that you can be proactive and make changes to your insurance plan as needed.

Understanding the Out-of-Pocket Costs for Clinical Trials

If you want to participate in a clinical trial, work with your treating physician to find a local one you qualify for. Willing to travel? That may increase the cost, but you can look for clinical trials here: HealthTree Clinical Trial Finder (scroll down on the page to search for clinical trials for your type of cancer).

After you’ve found a clinical trial, talk to the clinical trial coordinator to see what costs they cover. This will usually come through the clinical trial sponsor. Once you discover what they will pay for as part of the trial, determine what your insurance will pay for and what you will be responsible for prior to signing on the dotted line on the clinical trial contract.

Steps for Understanding Coverage

First, determine where the trial is being conducted. This will determine whether it is charged as in-network or out-of-network with your insurance. Be aware that some insurance plans do not cover out-of-network, so double check with both the trial hospital location and your insurance that coverage will apply. 

Estimate additional costs such as lodging, transportation, and food. Also, consider childcare costs if applicable.

Be aware that insurance may not cover some lab tests, your co-pays, or deductibles while in the clinical trial. However, your insurance must cover medically necessary routine care costs in clinical trials. 

For a clinical trial to be approved, it must have a written protocol already approved by an Institutional Review Board. Sometimes to be covered, the trial must be for a life-threatening condition. Remember, this can be interpreted differently by insurance plans.

There are Grandfathered insurance plans that may not cover trial participation. Grandfathered plans existed prior to the ACA enactment in March 2010.

Some clinical trials are known as paid clinical trials. These are usually Phase I trials in which the potential treatments need to be better understood, and it might be the first time these treatments are used within humans. Dosaging and side effects may be undetermined. Therefore, paid clinical trials also usually involve more risks.  

Fortunately, these trials usually reimburse you for your trial or will pay for childcare and travel costs. Always check with the trial sponsor before signing up to know what your covered and uncovered costs will be.

Tips for Getting Your Insurance to Cover Clinical Trial Costs

Here are steps you can take ahead of time to possibly reduce problems later.

• Collect journal articles from prior studies that explain the potential benefit of the treatment.
• Have your doctor submit a letter that explains the trial or why the trial is medically necessary for you.

• Give your insurance provider letters from any outside supporters of the trial, such as patient advocacy groups.

So, will insurance cover clinical trials? It’s not an easy “yes or no,” but it is possible for them to cover the costs if they deem it necessary. 

Will Insurance Pay for Second Opinions?

At some stage of your cancer journey, you might find it necessary or desirable to seek a second opinion from a different facility. 

Second opinions give you a fresh perspective and additional options so you can make a more informed decision regarding your treatment. 

Additionally, you may require a third opinion, particularly if there’s a huge difference between your first and second opinion. It is essentially a tiebreaker when the first two opinions are so different.

If you have Medicare Part B (traditional Medicare), it will cover the second opinion at 80%. The remaining 20% is covered through a supplement plan if you have one. If you don’t have a supplemental plan, you are responsible for 20%. You do not need a referral from your doctor.

If you’re covered under a Medicare Advantage Plan, you are also covered for second opinions. However, you may need to take additional steps to make this happen.

• You may need to get a referral from your doctor. 
• You may have to consult with a doctor in their designated network. (Sometimes second opinion doctors reside in the same practice). Be aware of your insurance provider's guidelines.

There’s a good argument for getting a second opinion from an unaffiliated practice. Hospitals and practices can be uniform when it comes to treatment recommendations.

You can either ask your doctor for an unaffiliated practice or search through Medicare’s Care Compare Tool at: Medicare.gov/care-compare.  

You can also search your plan's website for a second opinion to obtain a list of candidates.

To prevent duplication of tests, make sure your second opinion doctor has your medical records ahead of time. No one wants to have extra biopsies. If your second opinion doctor requires additional tests, they will be covered by your insurance.

Commercial insurance carriers will generally always pay for second and, if necessary, third opinions.

Does Insurance Pay for Telehealth Services?

Telehealth became very popular during the era of COVID-19 because you could have an appointment with your doctor without going into the office. It offers a wide range of medical care services, including primary care and urgent care. 

The cost of telehealth visits can vary, so it would be a good idea to check with your insurance company beforehand to avoid surprise billing. The costs also can vary depending on your health insurance coverage, health condition, and health care provider.

The costs associated with a primary care telehealth provider will be less than a telehealth visit with a specialist. Also, a telehealth visit for general medical advice will probably be significantly less expensive than a telehealth visit with a cancer specialist.

Your insurance may pay a portion of your telehealth visit or the entire visit cost. Your plan may or may not require you to pay co-pays, deductibles, or coinsurance. The point is to know your insurance, prior to using a service. You can always call the provider to ask about coverage. 

Medicaid has expanded in most states, but Medicaid reimbursements vary from state to state. To learn how your state has broadened telehealth coverage, go to: www.cchpca.org.

What are some of the telehealth service providers that Medicare will cover?

• Doctors
• Nurse Practitioners
• Licensed Social Workers

Again you may still be required to cover copays like you would do for regular office visits. Additionally, you will still be required to pay your Part B deductible. You may also still need prior authorization for the telehealth visit. 

Can You Save on Telehealth Visits?

You can do cost comparison shopping via GoodRx Telehealth marketplace for common services across popular telemedicine apps.

Because changes occur so often in the healthcare market, you need to keep abreast of possible changes for 2025.

In 2024, you can get telehealth wherever you are located. You don't have to be at an originating site, where patients get physician or practitioner medical services.

However, after December 2024:

• For non-behavioral or mental health, there may be originating site requirements and geographic location restrictions.
• For behavioral or mental issues, all patients can continue to get telehealth wherever they’re located, with no originating site or geographic location requirements.

Conclusion

Know your insurance and understand your coverage as much as possible before making any decisions about clinical trials, second opinion visits, or telehealth appointments. Be proactive in your care. Take advantage of the resources that are available to you and ask the right questions of your healthcare team.

If you would like to connect with me about financial resources for your blood cancer, you can email diahanna@healthtree.org. If you are a multiple myeloma patient, sign up for a free 1:1 visit with a financial coach by creating a profile at HealthTree Myeloma Coach and finding a coach that’s right for you.