Association of Fertility Preservation Benefit Mandates with Sperm Bank Network Adequacy: A Mixed Methods Study

INTRODUCTION: The effect of states mandating insurance coverage of fertility preservation for those facing iatrogenic infertility is unclear. We sought to qualitatively understand barriers to clinic acceptance of insurance coverage for sperm banking fertility preservation services and quantitatively estimate the association between mandated fertility benefits and clinics accepting insurance. MATERIALS AND METHODS: Staff at sperm banks in three "mandate states" completed in-depth interviews regarding patients accessing fertility preservation benefits through their insurance. Recruitment stopped at information saturation. Subsequently, a US-wide "secret shopper" study was completed of andrology/fertility clinics evaluating acceptance of insurance for sperm freezing services and cash costs of services for a fictitious male cancer patient. RESULTS: Seven interviews provided four dominant themes to describe clinic experience in mandated states: 1) coverage gaps/low reimbursement for sperm banking services 2) clinic resources needed to navigate insurance; 3) prior authorization care delays; and 4) need for sperm banks to educate patients and insurers on mandates. 200 of 418 clinics (56%) answered the secret shopper survey with a majority (69.5%, n=153) offering sperm banking services. Only 36.9% of these accepted insurance, with clinics in mandate states being more likely to accept insurance than in non-mandate states (61.0 vs. 27.8%, P-value = 0.0002). Only 37 (24.5%) of clinics provided cash cost of sperm banking (ranging from $50-$2000). CONCLUSIONS: The intent of fertility preservation mandates may be limited by barriers at insurer and clinic levels. Strategies to overcome barriers are needed to improve access to the full scope of fertility preservation benefits for male cancer patients.