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Legislation Document
SPONSOR:
Sen. Poore & Rep. Kamela Smith
Sens. Hoffner, Pinkney, Sturgeon; Reps. Berry, Burns, Gorman, Heffernan, Morrison, Neal, Romer, Ross Levin, Snyder-Hall
DELAWARE STATE SENATE
153rd GENERAL ASSEMBLY
SENATE BILL NO. 319
AN ACT TO AMEND TITLE 18, TITLE 29, AND TITLE 31 OF THE DELAWARE CODE RELATING TO COVERAGE FOR DIAGNOSTIC SERVICES AND TREATMENT FOR MENOPAUSE, PERIMENOPAUSE, AND MENOPAUSE AND PERIMENOPAUSE SYMPTOMS.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:
Section 1. Amend Chapter 33, Title 18 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§ 3370N. Coverage for diagnostic services and treatment for menopause and perimenopause.
(a) As used in this section:
(1) “Hormone replacement therapy” means medical treatment that replaces a hormone that an individual’s body is no longer making or no longer making enough of, as determined by a licensed health-care professional. “Hormone replacement therapy” includes prescribing any of the following:
a. A cream.
b. An oral medication.
c. A pellet medication.
d. A vaginal device.
e. Another method approved by the United States Food and Drug Administration.
(2) “Medically necessary”
means providing of health-care services or products that a prudent licensed health-care professional would provide to a patient for the purpose of diagnosing or treating menopause, perimenopause, menopause and perimenopause symptoms, and conditions associated with menopause or perimenopause in a manner that is all of the following:
a. In accordance with generally accepted standards of medical practice.
b. Consistent with the symptoms or treatment of the condition.
c. Not solely for anyone’s convenience.
d. Not including investigational or experimental health-care services.
(3) “Menopause” means the permanent end of menstruation due to loss of ovarian follicular function, characterized by the end of ovulation and a decline in estrogen and progesterone production.
(4) “Menopause and perimenopause symptoms” include any of the following:
a. Irregular menstrual periods.
b. Hot flashes.
c. Vaginal or bladder changes, including genitourinary syndrome of menopause.
d. Decreased fertility.
e. Loss of bone density, including osteoporosis.
f. Elevated low-density lipoprotein cholesterol levels.
g. Sleep disturbances, including night sweats.
(5) “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in the menstrual cycle.
(b)(1) All individual health insurance policies, contracts, or certificates that are delivered, issued for delivery,
renewed, extended, or modified in this State
must provide coverage for medically necessary diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms, including all of the following:
a. Consultation and diagnostic testing.
b. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration.
c. Non-hormonal treatments, including
selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause and perimenopause symptoms.
d. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms.
e. Therapy to treat menopause induced by a hysterectomy.
f. Behavioral health care services.
g. Pelvic floor physical therapy.
h. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications.
i. Preventative services
for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer.
j. Counseling and education regarding menopause management.
(2) An insurer shall provide clear and accessible information to each covered individual regarding covered menopause and perimenopause diagnostic services and treatment.
(3) Coverage for medically necessary hormone replacement therapy provided under this section may not be any of the following:
a. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms.
b. Subject to prior authorization or step therapy requirements.
(4) Except as otherwise provided in paragraph (b)(3) of this section, benefits provided under this section must be provided to covered individuals to the same extent as other benefits for any other medical condition covered under the individual health insurance policy, contract, or certificate.
(c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility.
(d) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited health insurance policies.
Section 2. Amend Chapter 35, Title 18 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§ 3571FF.
Coverage for diagnostic services and treatment for menopause and perimenopause.
(a) As used in this section:
(1) “Hormone replacement therapy” means a medical treatment that replaces a hormone that an individual’s body is no longer making or no longer making enough of, as determined by a licensed health-care professional. “Hormone replacement therapy” includes prescribing any of the following:
a. A cream.
b. An oral medication.
c. A pellet medication.
d. A vaginal device.
e. Another method approved by the United States Food and Drug Administration.
(2) “Medically necessary”
means providing of health-care services or products that a prudent licensed health-care professional would provide to a patient for the purpose of diagnosing or treating menopause, perimenopause, menopause and perimenopause symptoms, and conditions associated with menopause or perimenopause in a manner that is all of the following:
a. In accordance with generally accepted standards of medical practice.
b. Consistent with the symptoms or treatment of the condition.
c. Not solely for anyone’s convenience.
d. Not including investigational or experimental health-care services.
(3) “Menopause” means the permanent end of menstruation due to loss of ovarian follicular function, characterized by the end of ovulation and a decline in estrogen and progesterone production.
(4) “Menopause and perimenopause symptoms” include any of the following:
a. Irregular menstrual periods.
b. Hot flashes.
c. Vaginal or bladder changes, including genitourinary syndrome of menopause.
d. Decreased fertility.
e. Loss of bone density, including osteoporosis.
f. Elevated low-density lipoprotein cholesterol levels.
g. Sleep disturbances, including night sweats.
(5) “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in the menstrual cycle.
(b)(1) All group and blanket health insurance policies, contracts, or certificates that are delivered, issued for delivery,
renewed, extended, or modified in this State must provide
coverage for medically necessary diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms, including all of the following:
a. Consultation and diagnostic testing.
b. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration.
c. Non-hormonal treatments, including
selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause and perimenopause symptoms.
d. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms.
e. Therapy to treat menopause induced by a hysterectomy.
f. Behavioral health care services.
g. Pelvic floor physical therapy.
h. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications.
i. Preventative services
for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer.
j. Counseling and education regarding menopause management.
(2) An insurer shall provide clear and accessible information to each covered individual regarding covered menopause and perimenopause diagnostic services and treatment.
(3) Coverage for medically necessary hormone replacement therapy provided under this section may not be any of the following:
a. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms.
b. Subject to prior authorization or step therapy requirements.
(4) Except as otherwise provided in paragraph (b)(3) of this section, benefits provided under this section must be provided to covered individuals to the same extent as other benefits for any other medical condition covered under the group or blanket health insurance policy, contract, or certificate.
(c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility.
(d) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited health insurance policies.
(e)(1) If the coverage required under this section conflicts with a religious employer’s bona fide religious beliefs and practices, the religious employer may request that a policy, contract, or certificate include a coverage exclusion for the coverage required under this section. An insurer shall grant a coverage exclusion requested under this subsection.
(2) A religious employer that obtains an exclusion under this subsection shall give its employees reasonable and timely notice of the exclusion.
Section 3. Amend Chapter 52, Title 29 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§ 5224.
Coverage for diagnostic services and treatment for menopause and perimenopause.
(a) As used in this section:
(1) “Hormone replacement therapy” means a medical treatment that replaces a hormone that an individual’s body is no longer making or no longer making enough of, as determined by a licensed health-care professional. “Hormone replacement therapy” includes prescribing any of the following:
a. A cream.
b. An oral medication.
c. A pellet medication.
d. A vaginal device.
e. Another method approved by the United States Food and Drug Administration.
(2) “Medically necessary”
means providing of health-care services or products that a prudent licensed health-care professional would provide to a patient for the purpose of diagnosing or treating menopause, perimenopause, menopause and perimenopause symptoms, and conditions associated with menopause or perimenopause in a manner that is all of the following:
a. In accordance with generally accepted standards of medical practice.
b. Consistent with the symptoms or treatment of the condition.
c. Not solely for anyone’s convenience.
d. Not including investigational or experimental health-care services.
(3) “Menopause” means the permanent end of menstruation due to loss of ovarian follicular function, characterized by the end of ovulation and a decline in estrogen and progesterone production.
(4) “Menopause and perimenopause symptoms” include any of the following:
a. Irregular menstrual periods.
b. Hot flashes.
c. Vaginal or bladder changes, including genitourinary syndrome of menopause.
d. Decreased fertility.
e. Loss of bone density, including osteoporosis.
f. Elevated low-density lipoprotein cholesterol levels.
g. Sleep disturbances, including night sweats.
(5) “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in the menstrual cycle.
(b)(1)
The plan
must provide coverage for medically necessary diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms, including all of the following:
a. Consultation and diagnostic testing.
b. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration.
c. Non-hormonal treatments, including
selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause and perimenopause symptoms.
d. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms.
e. Therapy to treat menopause induced by a hysterectomy.
f. Behavioral health care services.
g. Pelvic floor physical therapy.
h. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications.
i. Preventative services
for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer.
j. Counseling and education regarding menopause management.
(2) A carrier shall provide clear and accessible information to each covered individual regarding covered menopause and perimenopause diagnostic services and treatment.
(3) Coverage for medically necessary hormone replacement therapy provided under this section may not be any of the following:
a. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms.
b. Subject to prior authorization or step therapy requirements.
(4) Except as otherwise provided in paragraph (b)(3) of this section, benefits provided under this section must be provided to covered individuals to the same extent as other benefits for any other medical condition covered under the plan.
(c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility.
Section 4. Amend Chapter 5, Title 31 of the Delaware Code by making deletions as shown by strike through and insertions as shown by underline as follows:
§
539.
Coverage for diagnostic services and treatment for menopause and perimenopause.
(a) As used in this section:
(1) “Hormone replacement therapy” means a medical treatment that replaces a hormone that an individual’s body is no longer making or no longer making enough of, as determined by a licensed health-care professional. “Hormone replacement therapy” includes prescribing any of the following:
a. A cream.
b. An oral medication.
c. A pellet medication.
d. A vaginal device.
e. Another method approved by the United States Food and Drug Administration.
(2) “Medically necessary”
means providing of health-care services or products that a prudent licensed health-care professional would provide to a patient for the purpose of diagnosing or treating menopause, perimenopause, menopause and perimenopause symptoms, and conditions associated with menopause or perimenopause in a manner that is all of the following:
a. In accordance with generally accepted standards of medical practice.
b. Consistent with the symptoms or treatment of the condition.
c. Not solely for anyone’s convenience.
d. Not including investigational or experimental health-care services.
(3) “Menopause” means the permanent end of menstruation due to loss of ovarian follicular function, characterized by the end of ovulation and a decline in estrogen and progesterone production.
(4) “Menopause and perimenopause symptoms” include any of the following:
a. Irregular menstrual periods.
b. Hot flashes.
c. Vaginal or bladder changes, including genitourinary syndrome of menopause.
d. Decreased fertility.
e. Loss of bone density, including osteoporosis.
f. Elevated low-density lipoprotein cholesterol levels.
g. Sleep disturbances, including night sweats.
(5) “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in the menstrual cycle.
(b)(1) Carriers shall provide coverage for medically diagnostic services and necessary treatment for menopause, perimenopause, and menopause and perimenopause symptoms in all health benefit plans delivered or issued for delivery under § 505(3) of this title, including all of the following:
a. Consultation and diagnostic testing.
b. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration.
c. Non-hormonal treatments, including
selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause and perimenopause symptoms.
d. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms.
e. Therapy to treat menopause induced by a hysterectomy.
f. Behavioral health care services.
g. Pelvic floor physical therapy.
h. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications.
i. Preventative services
for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer.
j. Counseling and education regarding menopause management.
(2) A carrier shall provide clear and accessible information to each recipient regarding covered menopause and perimenopause diagnostic services and treatment.
(3) Except as otherwise provided by federal law, coverage for medically necessary hormone replacement therapy provided under this section may not be any of the following:
a. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms.
b. Subject to prior authorization or step therapy requirements.
(4) Except as otherwise provided by paragraph (b)(3) of this section and federal law, assistance provided under this section must be provided to recipients to the same extent as other assistance for any other medical condition provided under § 505(3) of this title.
Section 5. This Act applies to all policies, contracts, or certificates that are issued, renewed, modified, altered, amended,
or reissued after December 31, 2027.
SYNOPSIS
This Act requires individual health insurance plans, group and blanket health insurance plans, the state employee health plan, and state Medicaid insurance to cover medically necessary diagnostic services and treatment for menopause, perimenopause, and symptoms of menopause or perimenopause, including all of the following:
1. Consultation and diagnostic testing.
2. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration.
3. Non-hormonal treatments, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause symptoms.
4. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms.
5. Therapy to treat menopause induced by a hysterectomy.
6. Behavioral health care services.
7. Pelvic floor physical therapy.
8. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications.
9. Preventative services for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer.
10. Counseling and education regarding menopause management.
Additionally, an insurer or carrier must provide clear and accessible information about covered menopause and perimenopause diagnostic services and treatment to each covered individual or Medicaid recipient. Menopause and perimenopause diagnostic and treatment benefits or assistance must be provided to the same extent as benefits or assistance for other medical conditions, but coverage for medically necessary hormone replacement therapy provided under this Act may not be any of the following, except as otherwise provided by federal Medicaid law:
1. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms.
2. Subject to prior authorization or step therapy requirements.
The Act provides a religious exemtion for group and blanket health policies. If the coverage requirement conflicts with a religious employer’s bona fide religious beliefs or practices, the religious employer may request a coverage exclusion for the coverage required under Section 2 of this Act and an insurer shall grant the exclusion. A religious employer who is granted an exclusion must give its employees reasonable and timely notice of the exclusion.
This Act applies to all policies, contracts, or certificates that are issued, renewed, modified, altered, amended, or reissued after December 31, 2027.
Author: Senator Poore