IMPORTANCEMultiple US states recently passed laws mandating health insurance coverage for fertility preservation (FP) services to improve access to care for patients with cancer, for whom FP service expenses can be prohibitive. Key unanswered questions include how heterogeneous benefit mandate laws and regulations are and how this variation may affect implementation, access, and utilization. OBJECTIVETo describe the design of state-level FP health insurance benefit mandate laws and regulations and derive guidance on best practices and implementation needs. DESIGN, SETTING, AND POPULATIONLegal mapping and implementation science frameworkguided analyses were conducted on 11 US state laws that mandate health insurance benefit coverage for FP services for patients at risk of iatrogenic infertility from medical treatments and on related insurer regulations. Design features of laws and regulations and the implementation process were summarized by themes (eg, coverage specification). EXPOSURES State jurisdiction. MAIN OUTCOMES AND MEASURESMain outcomes were the scope and specificity of mandated FP insurance coverage and the role of clinical practice guidelines and insurer regulations in implementation. RESULTSBetween June 2017 and March 2021, 11 states passed FP benefit mandate laws. States took a median (range) of 283 (0-640) days to implement mandates, and a majority issued regulatory guidance after the law was in effect. While standard-of-care procedures such as embryo cryopreservation require medical evaluation, medications, ultrasonography and laboratory monitoring, oocyte retrieval, embryo derivation, cryopreservation, and storage, there was variation in which services were specified for inclusion or exclusion in the laws and/or regulator guidance. The majority of state laws and regulator guidance reference medical society clinical practice guidelines and federal policies (Affordable Care Act and Health Insurance Portability and Accountability Act). CONCLUSIONS AND RELEVANCEIn this qualitative assessment of 11 state-level FP benefit mandates, variation that may influence patient access was identified in the design and implementation of the mandates. As clinical stakeholders aim to understand and/or shape these laws and their implementation, key considerations included specificity and flexibility of benefit design to be clinically meaningful, expansion of clinical practice guidelines to inform benefit coverage, inclusion of publicly insured and self-insured populations for universal access, and consistency between state and federal policies.
Background Recent reports indicated declines in HCV testing during the first half of 2020 in the United States due to COVID-19, but the longer-term impact on HCV testing and treatment is unclear. Methods We obtained monthly state-level volumes of HCV antibody, RNA and genotype testing and HCV treatment initiation, stratified by age and gender, spanning January 2019 until December 2020 from two large national labs (Quest and LabCorp). We performed segmented regression analysis for each state from a mixed effects Poisson regression model with Month as the main fixed predictor, and State as a random intercept. Results During the pre-COVID period (January 2019-March 2020), monthly HCV antibody and genotype tests decreased slightly while RNA tests and treatment initiations remained stable. Between March and April 2020, there were declines in the number of HCV antibody tests (37% reduction, p<0.001), RNA tests (37.5% reduction, p<0.001), genotype tests (24% reduction, p=0.023) and HCV treatment initiations (31%, p<0.001). Starting April 2020 through the end of 2020 there were significant increases in month-to-month HCV antibody (p<0.001), RNA (p=0.035), and genotype tests (p=0.047), but only antibody testing rebounded to pre-COVID levels. HCV treatment initiations remained low after April 2020 throughout the remainder of the year. Conclusion HCV testing and treatment dropped by over 30% during April 2020 at the start of the COVID pandemic, but while HCV testing increased again later in 2020, HCV treatment rates did not recover. Efforts should be made to link HCV positive patients to treatment and revitalize HCV treatment engagement by health care providers.
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