Accessibility of mandated coverage: Insurer and care team perspectives on barriers for cancer patients to receive insurance coverage for fertility preservation despite state-mandated coverage.

Abstract

e23038 Background: Several states require select insurers to cover fertility preservation for enrollees at risk of iatrogenic infertility; however, variability in mandate implementation remains. Massachusetts (MA) has mandated coverage by commercial insurers since July 2024 (Bill S.598). We sought to identify barriers for cancer patients to receive insurance coverage for fertility preservation despite state-mandated coverage in MA. Methods: We recruited pediatric and adult multidisciplinary cancer care team members at a MA academic cancer center and MA insurance industry employees for a qualitative interview guided by the Consolidated Framework for Implementation Research (CFIR). Transcripts were thematically analyzed using Atlas.ti. Results: Of 20 participants (65% female, 85% White), 14 were from the clinical setting (6 clinicians, 3 in operations, 2 administrative clinicians, 2 administrators, 1 in payor relations) and 6 were from the insurance setting (3 insurers, 2 clinicians employed by insurers, 1 regulator). Policy-level barriers included “ambiguity in terms of what is and isn’t covered...opaqueness in terms of how you get reimbursed” [operations], mandated coverage for the retrieval cycle but not for associated medications [administrator], state Medicaid policies (“the law excludes and strictly forbids Medicaid from covering [fertility preservation]” [insurance clinician]), and lack of clarity about whether mandates apply to insured dependents (“there is a lot of unknown information...even if they have fertility benefits, how would they affect a dependent?” [clinician]). Payor-level barriers included having a “general utilization management group that reviews requests” rather than a “specific infertility review department” [administrator]. Clinician/care setting-level barriers included clinicians lacking time to “look into nitty gritty details [of insurance mandates].” Patient-level barriers included limited “knowledge and appreciation of benefits” [insurer], limited awareness of mandates [clinician], switching to a health plan that no longer provides coverage [regulator], and urgency of treatment limiting time to appeal coverage denials [administrative clinician]. Conclusions: Despite a state mandate, multi-level barriers to accessing insurance coverage for fertility preservation were reported. Structural limitations at the policy level may shape the context in which the fertility preservation mandate is implemented across payors, clinicians/care settings, and patients. Alleviating the onus on patients by strengthening clinician/care setting capacity to help patients access their benefits may improve mandate implementation. Efforts to operationalize the mandate across levels are needed to reduce ongoing barriers despite formal requirements for coverage.