The Landscape of Coverage for Fertility Preservation in Male Pediatric Patients

The Patient Protection and Affordable Care Act(ACA) significantly increased the number of Americans with health insurance and has greatly improved access to health care services. However, states retain considerable jurisdiction over what benefits must be offered. The lack of a federal mandate for fertility preservation coverage results in a patchwork of benefits dependent on state statutes and regulation. Pediatric, adolescent and unmarried patients diagnosed with cancer or autoimmune diseases that impact fertility are often carved out of such coverage.

This review analyzed legislative and regulatory efforts in 10 states to determine the breadth of fertility preservation coverage in private, employer-based insurance plans and Medicaid, with particular interest in coverage for pediatric and adolescent patients.

Fifteen states require coverage of fertility preservation in private insurance plans; five states only extend this benefit to females. The statutes differ in terms of whom the coverage extends to based on marriage status, diagnosis, length of fertility problems, and the monetary limit of the benefit. Fertility preservation is not a mandatory benefit under federal Medicaid regulation, however states can opt to include it in their state Medicaid plan; no state currently covers fertility preservation as an optional benefit.

Coverage of fertility preservation is extremely limited both in scope of benefits and the number of states that require such a benefit. State governments can expand access to a fertility preservation benefit by removing spousal and expanding diagnostic criteria and by including the benefit in Medicaid plans.