Office of the Auditor | State of Hawai`i

Photo: Istock.com

AUDITOR’S SUMMARY

IN THE 2023 LEGISLATIVE SESSION, the Hawai‘i State Legislature contemplated mandating insurance coverage for standard fertility preservation services. Senate Bill No. 1446 (SB 1446) requires each individual or group health insurance policy to provide coverage to the policyholder and individuals under 26 years of age covered under the policy for standard fertility preservation services if they undergo a medically necessary treatment that may directly or indirectly cause iatrogenic infertility(1). In addition, House Concurrent Resolution No. 96 (HCR 96), also adopted in the Regular Session of 2023, requests the Auditor, in accordance with Sections 23-51 and 23-52, Hawai‘i Revised Statutes (HRS), to assess the social and financial effects of mandating health insurance coverage for fertility preservation services for certain insured persons who have been diagnosed with cancer and whose cancer or cancer treatment may adversely affect the insured person’s fertility.

HCR 96 further requests the Auditor to examine “the necessity of extending the mandatory health insurance coverage for fertility preservation procedures for the spouse or partner of an insured person who has been diagnosed with cancer or whose cancer treatment may adversely affect the insured person’s fertility, to allow the insured person to have a child in the future, and the social and financial effects of extending the mandatory coverage to such spouses or partners.”

In Report No. 23-11, Study of Proposed Mandatory Health Insurance Coverage for Standard Fertility Preservation Services, to conduct our assessment of the impacts of the proposed mandatory coverage for standard fertility preservation services as provided in SB 1446, we had to make numerous and significant assumptions about the Legislature’s intent in order to resolve certain ambiguities in SB 1446 and HCR 96. Among the assumptions we had to make was that any cancer-related medical treatment with a likely side effect of infertility would be covered under the proposed coverage. We also had to assume that coverage would not include the cost of storing cryopreserved material and that coverage had no maximum age for the policyholder. Additionally, SB 1446 specifically excludes a policyholder’s spouse from coverage for standard fertility preservation services as defined by SB 1446 if that spouse is aged 26 years or older.

If the bill is considered during the upcoming legislative session, we suggest the Legislature consider clarifying those parts of the bill to help insurers as well as the public better understand who, when, and what is covered by the mandate.

What is the Relationship Between Cancer and Fertility Preservation?
Cancer treatment can impact a person’s fertility. The effects of cancer treatment on fertility depends on a variety of factors, such as the medicine used, the size and location of the radiation field, the dose, dose intensity, or method of administration, or the age, sex, and fertility of the patient before treatment. In males, chemotherapy or radiotherapy can negatively affect sperm number, motility, morphology, and DNA integrity. In females, any treatment that decreases the number of primordial follicles(2), affects hormonal balance, or interferes with the functioning of the ovaries, fallopian tubes, uterus, or cervix can negatively affect fertility.

Additionally, surgical treatments for cancer can cause fertility problems such as through the removal of all or part of the testicles, penis, ovaries, uterus, or cervix.

Some aggressive forms of cancer such as leukemia require immediate treatment, while treatment for other forms of cancer may be delayed to allow a patient time to preserve their fertility. This is of particular importance for female patients, as they need additional time for stimulation and retrieval of their oocytes.(3)