<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".26-1" citation="COMAR 10.67.06.26-1" title_num="10" subtitle_num="67" chapter_num="06" heading="Clinical Trial Items and Services — Coverage for Routine Costs.">
  <paragraph num="A.">
    <text>Subject to the conditions specified in §§B—F of this regulation, an MCO shall provide coverage for cost to an enrollee in an approved clinical trial for:</text>
    <paragraph num="(1)">
      <text>Treatment provided for life-threatening conditions; or</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Prevention, early detection, and treatment studies on cancer.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Clinical trials are deemed to be automatically approved if:</text>
    <paragraph num="(1)">
      <text>The treatment is:</text>
      <paragraph num="(a)">
        <text>Being provided or the studies are being conducted in a Phase I, Phase II, Phase III, or Phase IV clinical trials for cancer; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Being provided in Phase I, Phase II, Phase III, or Phase IV clinical trial for any other life-threatening condition;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The treatment is being provided in a clinical trial:</text>
      <paragraph num="(a)">
        <text>Approved by:</text>
        <paragraph num="(i)">
          <text>The National Institutes of Health (NIH);</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>An NIH cooperative group or an NIH center;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The Centers for Disease Control and Prevention;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>The Agency for Healthcare Research and Quality;</text>
        </paragraph>
        <paragraph num="(v)">
          <text>The Centers for Medicare and Medicaid Services (CMS);</text>
        </paragraph>
        <paragraph num="(vi)">
          <text>The Department of Defense;</text>
        </paragraph>
        <paragraph num="(vii)">
          <text>The Department of Veterans Affairs; or</text>
        </paragraph>
        <paragraph num="(viii)">
          <text>An institutional review board of an institution in the State that has a multiple project assurance contract approved by the Office of Protection from Research Risks of the NIH; or</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Conducted:</text>
        <paragraph num="(i)">
          <text>At National Cancer Institute Centers;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Under Investigational New Drug application (IND) reviewed by the Food and Drug Administration (FDA); or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>As a clinical trial with deemed status through an exemption from having an IND under 21 CFR §312.2(b)(1);</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The facility and the personnel providing the treatment are capable of doing so by virtue of the facility and the personnel's experience, training, and volume of patients treated to maintain expertise;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>There is no clearly superior, non-investigational treatment alternative; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the non-investigational alternative.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Enrollee cost includes the following:</text>
    <paragraph num="(1)">
      <text>The cost of all medically necessary items and services that are otherwise available to Medicaid beneficiaries such as hospital services, physician services, or diagnostic tests; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The cost of medically necessary items or services required solely for the provision of the following:</text>
      <paragraph num="(a)">
        <text>Investigational item or service such as administration of a noncovered chemotherapeutic agent;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The clinically appropriate monitoring of the effects of the item or service; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The prevention, diagnosis, and treatment of complications.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Enrollee cost does not include the following:</text>
    <paragraph num="(1)">
      <text>The cost of the investigational item or service itself;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The cost of items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the enrollee;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The cost of items and services customarily provided by the research sponsors free of charge for any enrollee in the trial; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The cost of non-health care services that an enrollee may be required to receive as a result of the treatment being provided for purposes of the clinical trial.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>If the enrollee has insurance or other coverage, or if any other person is obligated, either legally or contractually, to pay for, or to reimburse the enrollee for, services covered by this regulation, the provider shall seek payment from that source first.</text>
  </paragraph>
  <paragraph num="F.">
    <text>The MCO shall authorize the request for participation in an approved clinical trial within 72 hours of the request.</text>
  </paragraph>
</regulation>