Improving Implementation of Fertility Preservation Benefit Mandates

Importance: More than 90 000 adolescents and young adults are diagnosed with cancer and exposed to treatments that may threaten their future fertility every year. Fertility preservation (FP) services, such as egg, embryo, and sperm freezing, are available to preserve future fertility but are often underused by patients in part due to high cost. Eighteen states and Washington, DC, recently began mandating health insurance coverage for FP services, yet patients and clinicians report difficulty accessing mandated services. Objective: To systematically identify determinants of implementing FP benefit mandates in fertility and oncology clinics to inform intervention development and future public policy. Design, Setting, and Participants: In this mixed-methods study, fertility and oncology clinics from California, Illinois, and New York were selected from the 8 states that had FP benefit mandates in place in 2020 to maximize diversity of the state-level characteristics that may impact mandate implementation. Fertility and oncology clinic representatives (health care clinicians, financial counselors, and other administrative personnel) identified as being the most knowledgeable regarding implementation of FP benefit mandates were interviewed or surveyed using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Interviews and surveys were conducted from July 2020 to November 2023, and data were analyzed from September 2022 to June 2024. Exposure: Passage of a state-level FP benefit mandate. Main Outcomes and Measures: Barriers and facilitators to implementing access to FP benefits after mandate passage at clinic and patient levels. Results: This study included 48 participants from 24 oncology and fertility clinics and 2 fertility pharmacies. Interviews (n = 48) and surveys (n = 17) were used to identify determinants of successful FP benefit mandate implementation. The top 3 barriers identified included (1) time-consuming nature of interactions between clinics and insurers, (2) patients' lack of knowledge on their benefits and how to find them, and (3) holes in coverage and heterogeneity of benefits across health insurance plans. The top 3 facilitators included (1) dedicated clinic financial counselors who guide patients on benefit verification, (2) clearly defined FP benefits in member handbooks, and (3) health insurance plan preexisting in vitro fertilization insurance benefit. Conclusions and Relevance: In this study, multiple barriers and facilitators were systematically identified to assist in improving implementation of FP benefit mandates. These findings support policies and intervention development for FP patients and clinics, and future legislative and regulatory efforts aimed at increasing timely access to FP insurance benefits.