42 Implementation of California's fertility preservation health insurance benefit mandate

Abstract

California passed legislation in 2019 mandating health insurance coverage of fertility preservation (FP) for patients facing iatrogenic infertility to improve access to care and reduce medical financial hardship. The objectives of this qualitative study are to assess insurer- and clinic-level implementation practices and identify barriers and facilitators to accessing FP insurance benefits that impact service and patient outcomes. Using purposeful sampling, twenty semi-structured interviews were conducted with insurers, physicians, clinic navigators, and financial counselors from eight adult and pediatric oncology and fertility clinics in southern California. Thematic analysis guided by Bullock's (2021) framework for policy implementation and inductive codes was undertaken. At the insurer level, health benefit design standardization is limited therefore downstream training and modification of patient- and clinic-facing resources (benefit verification staff, member benefit handbooks) that reflect FP benefits are heterogeneous. At the clinic level, navigators and financial counselors addressed this heterogeneity by implementing multi-prong, time- and resource-consuming processes in interacting with these insurer resources and report that accessing benefits is complex, inconsistent, prolonged and frequently ineffective. For patient outcomes, clinic navigators report patient psychosocial distress manifested as marital problems or incurring debt by credit card use. Policies intended to improve access to care need effective downstream implementation. Heterogeneous insurer implementation of the state-level FP health insurance benefit mandate has resulted in expenditure of excessive clinic resources to assist patients in accessing urgent FP care that are not feasible, appropriate, or effective. To alleviate medical financial hardship and distress in patients facing iatrogenic infertility, insurers need to improve benefit mandate implementation to support access, and clinics need scalable, effective insurance navigation interventions.