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<section article="gin" article_name="Insurance" number="15-827" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits">
  <level label="a">
    <level label="1">
      <text>In this section the following words have the meanings indicated.</text>
    </level>
    <level label="2">
      <level label="i">
        <text>“Cooperative group” means a formal network of facilities that collaborate on research projects and have an established NIH-approved Peer Review Program operating within the group.</text>
      </level>
      <level label="ii">
        <text>“Cooperative group” includes:</text>
        <level label="1">
          <text>the National Cancer Institute Clinical Cooperative Group;</text>
        </level>
        <level label="2">
          <text>the National Cancer Institute Community Clinical Oncology Program;</text>
        </level>
        <level label="3">
          <text>the AIDS Clinical Trials Group; and</text>
        </level>
        <level label="4">
          <text>the Community Programs for Clinical Research in AIDS.</text>
        </level>
      </level>
    </level>
    <level label="3">
      <text>“FDA” means the federal Food and Drug Administration.</text>
    </level>
    <level label="4">
      <text>“Member” means a policyholder, subscriber, insured, or certificate holder or a covered dependent of a policyholder, subscriber, insured, or certificate holder.</text>
    </level>
    <level label="5">
      <text>“Multiple project assurance contract” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.</text>
    </level>
    <level label="6">
      <text>“NIH” means the National Institutes of Health.</text>
    </level>
    <level label="7">
      <level label="i">
        <text>“Patient cost” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to the member for purposes of the clinical trial.</text>
      </level>
      <level label="ii">
        <text>“Patient cost” does not include:</text>
        <level label="1">
          <text>the cost of an investigational drug or device;</text>
        </level>
        <level label="2">
          <text>the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of the clinical trial;</text>
        </level>
        <level label="3">
          <text>costs associated with managing the research associated with the clinical trial; or</text>
        </level>
        <level label="4">
          <text>costs that would not be covered under the patient’s policy, plan, or contract for noninvestigational treatments.</text>
        </level>
      </level>
    </level>
  </level>
  <level label="b">
    <text>This section applies to:</text>
    <level label="1">
      <text>insurers and nonprofit health service plans that provide hospital, medical, surgical, or pharmaceutical benefits to individuals or groups on an expense-incurred basis under a health insurance policy or contract issued or delivered in the State; and</text>
    </level>
    <level label="2">
      <text>health maintenance organizations that provide hospital, medical, surgical, or pharmaceutical benefits to individuals or groups under contracts that are issued or delivered in the State.</text>
    </level>
  </level>
  <level label="c">
    <text>This section does not apply to a policy, plan, or contract paid for under Title XVIII or Title XIX of the Social Security Act.</text>
  </level>
  <level label="d">
    <text>A policy, plan, or contract subject to this section shall provide coverage for patient cost to a member in a clinical trial, as a result of:</text>
    <level label="1">
      <text>treatment provided for a life-threatening condition; or</text>
    </level>
    <level label="2">
      <text>prevention, early detection, and treatment studies on cancer.</text>
    </level>
  </level>
  <level label="e">
    <text>The coverage under subsection (d) of this section shall be required if:</text>
    <level label="1">
      <level label="i">
        <text>the treatment is being provided or the studies are being conducted in a Phase I, Phase II, Phase III, or Phase IV clinical trial for cancer; or</text>
      </level>
      <level label="ii">
        <text>the treatment is being provided in a Phase I, Phase II, Phase III, or Phase IV clinical trial for any other life-threatening condition;</text>
      </level>
    </level>
    <level label="2">
      <text>the treatment is being provided in a clinical trial approved by:</text>
      <level label="i">
        <text>one of the National Institutes of Health;</text>
      </level>
      <level label="ii">
        <text>an NIH cooperative group or an NIH center;</text>
      </level>
      <level label="iii">
        <text>the FDA in the form of an investigational new drug application;</text>
      </level>
      <level label="iv">
        <text>the federal Department of Veterans Affairs; or</text>
      </level>
      <level label="v">
        <text>an institutional review board of an institution in the State which has a multiple project assurance contract approved by the Office of Protection from Research Risks of the National Institutes of Health;</text>
      </level>
    </level>
    <level label="3">
      <text>the facility and personnel providing the treatment are capable of doing so by virtue of their experience, training, and volume of patients treated to maintain expertise;</text>
    </level>
    <level label="4">
      <text>there is no clearly superior, noninvestigational treatment alternative; and</text>
    </level>
    <level label="5">
      <text>the available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative.</text>
    </level>
  </level>
  <level label="f">
    <text>In conjunction with the provisions of subsection (d) of this section, a policy, plan, or contract shall provide coverage for patient cost incurred for drugs and devices that have been approved for sale by the FDA whether or not the FDA has approved the drug or device for use in treating the patient’s particular condition, to the extent that the drugs or devices are not paid for by the manufacturer, distributor, or provider of that drug or device.</text>
  </level>
  <level label="g">
    <level label="1">
      <text>An entity seeking coverage for treatment in a clinical trial approved by an institutional review board under subsection (e)(2)(v) of this section shall post electronically and keep up-to-date a list of the clinical trials meeting the requirements of subsections (d) and (e) of this section.</text>
    </level>
    <level label="2">
      <text>The list shall include, for each clinical trial:</text>
      <level label="i">
        <text>the phase for which the trial is approved;</text>
      </level>
      <level label="ii">
        <text>the entity approving the trial;</text>
      </level>
      <level label="iii">
        <text>whether the trial is for treatment of cancer or another life-threatening disease and, if not cancer, the particular disease; and</text>
      </level>
      <level label="iv">
        <text>the estimated number of participants in the trial.</text>
      </level>
    </level>
  </level>
  <level label="h">
    <text>This section may not be construed to affect compliance with § 15-804 of this subtitle regarding coverage for off-label use of drugs.</text>
  </level>
</section>
