Table 1 Implementation, service, and patient outcomes from stakeholder perspectives
Source | Outcome | Perspective |
|---|---|---|
Implementation | ||
Legislation (Big P) | Lawsuits by insurers to state to delay implementation of benefits | Regulator Insurers |
Legislation (Big P) and regulator guidance (Big P) | Heterogeneity in benefit design in response to lack of fertility preservation services coverage specifics | Insurers |
Insurer communication with members (little p) | Lack of or inconsistent fertility preservation benefit information through insurer member services, online member portals, evidence of coverage/plan handbook documents, and insurer communication with clinics | Clinics Patients |
Insurer communication with clinics (little p) | Lack of or inconsistent fertility preservation benefit information through insurer provider services and portals, insurer communication with members | Clinics Patients |
Heterogeneous insurer processes for benefit verification, prior authorization, and claims (little p) | Time-consuming, parallel processes by clinics and patients for accessing fertility preservation benefits | Clinics Patients |
Insurer system configuration of fertility preservation diagnostic and service codes and in-network providers and facilities (little p) | Incomplete or errors in coding system lead to members and clinics misinformed that there is no benefit or not in network, clinics not getting reimbursed | Clinics Patients |
Contracts between insurer and clinics (little p) | Lack of contracts or paired fertility preservation providers and facilities that are both in network for members give rise to need for letters of agreement for individual patients and delays in care | Clinics Patients |
Payment requirements of patients (little p) | Clinics are unsure of insurance reimbursement and set policies to ask patients to pay cash costs up front | Clinics Patients |
Service | ||
Legislation (Big P) | Populations not covered (i.e., uninsured, publicly insured, self-insured) render policy “leaky” | Clinics Patients and advocates |
Benefit design (little p) | Not all medically indicated fertility preservation services are covered, high out-of-pocket costs, and fertility preservation benefit not at parity with other benefits result in coverage gaps and lack of access to services | Insurers Clinics Patients and advocates |
Contracts between insurer and clinics (little p) | Few or no in-network fertility preservation providers and facilities prevent access | Clinics Patients and advocates |
Heterogeneous insurer processes for benefit verification and prior authorization (little p) | Without confirmed benefits, patients forgo consultation and treatments | Clinics Patients and advocates |
Payment requirements of patients (little p) | Clinics are unsure of insurance reimbursement and ask patients to pay cash costs up front. Patients who cannot afford cash costs forgo services | Clinics Patients |
Dissemination of information on legislation and covered fertility preservation benefits | Providers may not offer, and patients may not access fertility preservation services if they do not know that there are insurance benefits | Clinics Patients and advocates |
Patient and long-term health | ||
Benefit design (little p) | High out-of-pocket costs result in patient distress, financial toxicity, and behaviors such as mortgaging homes to pay for fertility preservation services | Clinics Patients and advocates |
Heterogeneous insurer processes for benefit verification, prior authorization, and claims (little p) | Time-consuming and lack of resolution result in patient distress, medical financial toxicity | Clinics Patients |