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S4054
SENATE, No. 4054
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED MARCH 23, 2026
Sponsored by:
Senator� JOHN J. BURZICHELLI
District 3 (Cumberland, Gloucester and Salem)
SYNOPSIS
���� Clarifies that testosterone therapy is covered
treatment under the �New Jersey Menopause Coverage Act.�
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act
concerning health insurance coverage of
perimenopause and menopause services and amending various parts of the
statutory law.
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� Section 1 of P.L.2025,
c.200 (C.17:48-6bbb) is amended to read as follows:
���� 1.��� a.� A hospital service
corporation contract that provides hospital or medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1938,
c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance on or after the effective date of P.L.2025,
c.200 (C.17:48-6bbb et al.), shall provide benefits to any named subscriber or
other person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
���� (1)�� hormonal therapies such
as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
���� (2)�� non-hormonal treatments,
including medications to manage perimenopause and menopausal symptoms;
���� (3)�� behavioral health care
services;
���� (4)�� pelvic floor physical
therapy;
���� (5)�� bone health treatments,
including screenings
and medications due to hormonal changes related to
perimenopause and menopause;
���� (6)�� preventative services that
have a rating of �A� or �B� in the current recommendations of the United States
Preventive Services Task Force for early detection and treatment of health
conditions related to perimenopause and menopause such as osteoporosis and
cancer; and
���� (7)�� counseling regarding
menopause management.
���� b.���
Benefits for
testosterone therapy, prescribed pursuant to paragraph (1) of subsection a. of
this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a hospital service
corporation if the prescribed therapy is not indicated by the federal Food and
Drug Administration to be approved for perimenopause or menopause.
����
c.
���� A hospital
service corporation shall provide clear and accessible information to
subscribers or covered persons regarding covered perimenopause and menopause
treatments.
����
[
c.
]
d.
� The benefits shall be
provided to the same extent as for any other medical condition under the
contract.
����
[
d.
]
e.
� The provisions of
this section shall apply to all hospital service corporation contracts in which
the hospital service corporation has reserved the right to change the premium.
����
[
e.
]
f.
� As used in this
section:
���� �Menopause� means the
permanent end of a female�s menstrual cycle, diagnosed by a licensed medical
provider after 12 consecutive months without a menstrual period.
����� �Perimenopause� means the
transitional period leading to menopause, marked by fluctuating hormone levels
and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.1)
���� 2.��� Section 2 of P.L.2025,
c.200 (C.17:48A-7yy) is amended to read as follows:
���� 2.��� a.� Every medical
service corporation contract that provides hospital or medical expense benefits
and is delivered, issued, executed or renewed in this State pursuant to
P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in
this State by the Commissioner of Banking and Insurance on or after the
effective date of P.L.2025, c.200 (C.17:48-6bbb et al.), shall provide benefits
to any named subscriber or other person covered thereunder for expenses
incurred in obtaining medically necessary treatment for women with a diagnosis
of perimenopause, menopause, and symptoms associated with perimenopause and
menopause, including but not limited to:
���� (1)�� hormonal therapies such
as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
���� (2)�� non-hormonal treatments,
including medications to manage perimenopause and menopausal symptoms;
���� (3)�� behavioral health care
services;
���� (4)�� pelvic floor physical
therapy;
���� (5)�� bone health treatments,
including screenings and medications due to hormonal changes related to
perimenopause and menopause;
���� (6)�� preventative services that
have a rating of �A� or �B� in the current recommendations of the United States
Preventive Services Task Force for early detection and treatment of health
conditions related to perimenopause and menopause such as osteoporosis and
cancer; and
���� (7)�� counseling and education
regarding menopause management.
���� b.���
Benefits for
testosterone therapy, prescribed pursuant to paragraph (1) of subsection a. of
this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a medical service
corporation if the prescribed therapy is not indicated by the federal Food and
Drug Administration to be approved for perimenopause or menopause.
����
c.
���� A medical
service corporation shall provide clear and accessible information to
subscribers or covered persons regarding covered perimenopause and menopause
treatments.
����
[
c.
]
d.
� The benefits shall be
provided to the same extent as for any other medical condition under the
contract.
����
[
d.
]
e.
� The provisions of
this section shall apply to all medical service corporation contracts in which
the medical service corporation has reserved the right to change the premium.
����
[
e.
]
f.
� As used in this
section:
���� �Menopause� means the
permanent end of a female�s menstrual cycle, diagnosed by a licensed medical
provider after 12 consecutive months without a menstrual period.
���� �Perimenopause� means the
transitional period leading to menopause, marked by fluctuating hormone levels
and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.2)
���� 3.��� Section 3 of P.L.2025,
c.200 (C.17:48E-35.52) is amended to read as follows:
���� 3.��� a.� Every health service
corporation contract that provides hospital or medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1985,
c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance on or after the effective date of P.L.2025,
c.200 (C.17:48-6bbb et al.), shall provide benefits to any named subscriber or
other person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
���� (1)�� hormonal therapies such
as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
���� (2)�� non-hormonal treatments,
including medications to manage perimenopause and menopausal symptoms;
���� (3)�� behavioral health care
services;
���� (4)�� pelvic floor physical
therapy;
���� (5)�� bone health treatments,
including screenings and medications due to hormonal changes related to
perimenopause and menopause;
���� (6)�� preventative services that
have a rating of �A� or �B� in the current recommendations of the United States
Preventive Services Task Force for early detection and treatment of health
conditions related to perimenopause and menopause such as osteoporosis and
cancer; and
���� (7)�� counseling and education
regarding menopause management.
���� b.���
Benefits for
testosterone therapy, prescribed pursuant to paragraph (1) of subsection a. of
this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a health service
corporation if the prescribed therapy is not indicated by the federal Food and
Drug Administration to be approved for perimenopause or menopause.
����
c.
���� A health service
corporation shall provide clear and accessible information to subscribers or
covered persons regarding covered perimenopause and menopause treatments.
����
[
c.
]
d.
� The benefits shall be
provided to the same extent as for any other medical condition under the
contract.
����
[
d.
]
e.
� The provisions of
this section shall apply to all health service corporation contracts in which
the health service corporation has reserved the right to change the premium.
����
[
e.
]
f.
� As used in this
section:
���� �Menopause� means the
permanent end of a female�s menstrual cycle, diagnosed by a licensed medical
provider after 12 consecutive months without a menstrual period.
���� �Perimenopause� means the
transitional period leading to menopause, marked by fluctuating hormone levels
and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.3)
���� 4.��� Section 4 of P.L.2025,
c.200 (C. 17B:26-2.1uu) is amended to read as follows:
���� 4.��� a.� Every individual
policy that provides hospital or medical expense benefits and is delivered,
issued, executed or renewed in this State pursuant to N.J.S. 17B:26-1 et seq.,
or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance on or after the effective date of P.L.2025, c.200
(C.17:48-6bbb et al.), shall provide benefits to any named insured or other
person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
���� (1)�� hormonal therapies such
as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
���� (2)�� non-hormonal treatments,
including medications to manage perimenopause and menopausal symptoms;
���� (3)�� behavioral health care
services;
���� (4)�� pelvic floor physical
therapy;
���� (5)�� bone health treatments,
including screenings and medications due to hormonal changes related to
perimenopause and menopause;
���� (6)�� preventative services that
have a rating of �A� or �B� in the current recommendations of the United States
Preventive Services Task Force for early detection and treatment of health
conditions related to perimenopause and menopause such as osteoporosis and
cancer; and
���� (7)�� counseling and education
regarding menopause management.
���� b.���
Benefits for
testosterone therapy, prescribed pursuant to paragraph (1) of subsection a. of
this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by an individual policy if
the prescribed therapy is not indicated by the federal Food and Drug
Administration to be approved for perimenopause or menopause.
����
c.
���� Every individual
policy shall provide clear and accessible information to insureds regarding
covered perimenopause and menopause treatments.
����
[
c.
]
d.
� The benefits shall be
provided to the same extent as for any other medical condition under the
policy.
����
[
d.
]
e.
� The provisions of
this section shall apply to all health insurance policies in which the insurer
has reserved the right to change the premium.
����
[
e.
]
f.
� As used in this
section:
���� �Menopause� means the
permanent end of a female�s menstrual cycle, diagnosed by a licensed medical
provider after 12 consecutive months without a menstrual period.
����� �Perimenopause� means the
transitional period leading to menopause, marked by fluctuating hormone levels
and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.4)
���� 5.��� Section 5 of P.L.2025,
c.200 (C.17B:27-46.1aaa) is amended to read as follows:
����� 5.�� a.�
Every group health policy that provides hospital or
medical expense benefits and is delivered, issued, executed or renewed in this
State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal
in this State by the Commissioner of Banking and Insurance on or after the
effective date of
P.L.2025, c.200 (C.17:48-6bbb et al.)
, shall provide benefits to any named insured or
other person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage perimenopause and menopausal
symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a group policy if the
prescribed therapy is not indicated by the federal Food and Drug Administration
to be approved for perimenopause or menopause.
�����
c.
�� Every group policy shall provide clear and
accessible information to insureds regarding covered perimenopause and
menopause treatments.
�����
[
c.
]
d.
� The benefits shall be provided to
the same extent as for any other medical condition under the policy.
�����
[
d.
]
e.
� The provisions of this section
shall apply to all policies in which the insurer has reserved the right to
change the premium.
�����
[
e.
]
f.
� As used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.5)
���� 6.��� Section 6 of P.L.2025,
c.200 (C.26:2J-4.53) is amended to read as follows:
����� 6.�� a.�
Every enrollee agreement that provides hospital or
medical expense benefits and is delivered, issued, executed or renewed in this
State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance
or renewal in this State by the Commissioner of Banking and Insurance on or
after the effective date of
P.L.2025, c.200 (C.17:48-6bbb et al.)
, shall provide benefits to any enrollee or other
person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause and menopause,
including but not limited to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage menopausal symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a health maintenance
organization if the prescribed therapy is not indicated by the federal Food and
Drug Administration to be approved for perimenopause or menopause.
�����
c.
�� A health maintenance organization shall provide
clear and accessible information to enrollees regarding covered perimenopause
and menopause treatments.
�����
[
c.
]
d.
� The benefits shall be provided to
the same extent as for any other medical condition under the enrollee
agreement.
�����
[
d.
]
e.
� The provisions of this section
shall apply to all enrollee agreements in which the health maintenance
organization has reserved the right to change the schedule of charges.
�����
[
e.
]
f.
� As used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.6)
���� 7.��� Section 7 of P.L.2025,
c.200 (C.17B:27A-7.36) is amended to read as follows:
����� 7.�� a.�
Every individual health benefits plan that provides
hospital or medical expense benefits and is delivered, issued, executed or
renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or
approved for issuance or renewal in this State by the Commissioner of Banking
and Insurance on or after the effective date of
P.L.2025, c.200
(C.17:48-6bbb et al.)
, shall provide benefits
to any person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage menopausal symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by an individual health
benefits plan if the prescribed therapy is not indicated by the federal Food
and Drug Administration to be approved for perimenopause or menopause.
�����
c.
�� An individual health benefits plan shall provide
clear and accessible information to a covered person regarding covered
perimenopause and menopause treatments.
�����
[
c.
]
d.
� The benefits shall be provided to
the same extent as for any other medical condition under the health benefits
plan.
��� [
d.
]
e.
� The provisions of this section
shall apply to all enrollee agreements in which the insurer has reserved the
right to change the premium.
�����
[
e.
]
f.
� As used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.7)
���� 8.��� Section 8 of P.L.2025,
c.200 (C.17B:27A-19.40) is amended to read as follows:
����� 8.�� a.�
Every small employer health benefits plan that
provides hospital or medical expense benefits and is delivered, issued,
executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et
seq.), or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance on or after the effective date of
P.L.2025, c.200
(C.17:48-6bbb et al.)
, shall provide benefits
to any person covered thereunder for expenses incurred in obtaining medically
necessary treatment for women with a diagnosis of perimenopause, menopause, and
symptoms associated with perimenopause and menopause, including but not limited
to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage menopausal symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a small employer health
benefits plan if the prescribed therapy is not indicated by the federal Food
and Drug Administration to be approved for perimenopause or menopause.
�����
c.
�� A small employer health benefits plan shall
provide clear and accessible information to a covered person regarding covered
perimenopause and menopause treatments.
�����
[
c.
]
d.
� The benefits shall be provided to
the same extent as for any other medical condition under the health benefits
plan.
�����
[
d.
]
e.
� The provisions of this section
shall apply to all enrollee agreements in which the insurer has reserved the
right to change the premium.
�����
[
e.
]
f.
� As used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.8)�
���� 9.��� Section 9 of P.L.2025,
c.200 (C.52:14-17.29pp) is amended to read as follows:
����� 9.�� a.
�The State Health Benefits Commission shall ensure
that every contract purchased by the commission on or after the effective date
of
P.L.2025, c.200 (C.17:48-6bbb et al.)
, that provides hospital or medical expense benefits, shall provide
benefits to any person covered thereunder for expenses incurred in obtaining
medically necessary treatment for women with a diagnosis of perimenopause,
menopause, and symptoms associated with perimenopause and menopause, including
but not limited to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage menopausal symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a contract purchased by
the State Health Benefits Commission if the prescribed therapy is not indicated
by the federal Food and Drug Administration to be approved for perimenopause or
menopause.
�����
c.
�� The State Health Benefits Commission shall ensure
that each contract shall provide clear and accessible information to a covered
person regarding covered perimenopause and menopause treatments.
�����
[
c.
]
d.
� The benefits shall be provided to
the same extent as for any other medical condition under the contract.
�����
[
d.
]
e.
� As used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.9)
���� 10.� Section 10 of P.L.2025,
c.200 (C.52:14-17.46.6x) is amended to read as follows:
����� 10. a.�
The School Employees� Health Benefits Commission
shall ensure that every contract purchased by the commission on or after the
effective date of
P.L.2025, c.200 (C.17:48-6bbb et al.)
, that provides hospital or medical expense
benefits, shall provide benefits to any person covered thereunder for expenses
incurred in obtaining medically necessary treatment for women with a diagnosis
of perimenopause, menopause, and symptoms associated with perimenopause and
menopause, including but not limited to:
����� (1)�
hormonal
therapies such as hormone replacement therapy
[
and
]
,
bioidentical hormone treatments
, and testosterone therapy
;
����� (2)� non-hormonal
treatments, including medications to manage menopausal symptoms;
����� (3)� behavioral
health care services;
����� (4)� pelvic
floor physical therapy;
����� (5)� bone
health treatments, including screenings and medications due to hormonal changes
related to perimenopause and menopause;
����� (6)� preventative
services that have a rating of �A� or �B� in the current recommendations of the
United States Preventive Services Task Force for early detection and treatment
of health conditions related to perimenopause and menopause such as
osteoporosis and cancer; and
����� (7)� counseling
and education regarding menopause management.
���� b.���
Benefits
for testosterone therapy, prescribed pursuant to paragraph (1) of subsection a.
of this section, shall be provided to the same extent as for any hormonal
treatment under this section and shall not be denied by a contract purchased by
the School Employees� Health Benefits Commission if the prescribed therapy is
not indicated by the federal Food and Drug Administration to be approved for
perimenopause or menopause.
�����
c.
�� The School Employees
�
Health Benefits
Commission shall ensure that each contract shall provide clear and accessible
information to a covered person regarding covered perimenopause and menopause
treatments.
����� c.�� The
benefits shall be provided to the same extent as for any other medical
condition under the contract.
����� d.�� As
used in this section:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
(cf: P.L.2025, c.200, s.10)
����� 11.
Section 6 of P.L.1968, c.413 (C.30:4D-6) is amended to read as follows:
����� 6.
�a.� Subject to the requirements of Title XIX of the federal Social Security
Act, the limitations imposed by this act and by the rules and regulations
promulgated pursuant thereto, the department shall provide medical assistance
to qualified applicants, including authorized services within each of the
following classifications:
����� (1)
�Inpatient hospital services
����� (2)
�Outpatient hospital services;
����� (3)
�Other laboratory and X-ray services;
����� (4)
�(a) �Skilled nursing or intermediate care facility services;
����� (b)
�Early and periodic screening and diagnosis of individuals who are eligible
under the program and are under age 21, to ascertain their physical or mental
health status and the health care, treatment, and other measures to correct or
ameliorate defects and chronic conditions discovered thereby, as may be
provided in regulation of the Secretary of the federal Department of Health and
Human Services and approved by the commissioner;
����� (5)
�Physician's services furnished in the office, the patient's home, a hospital,
a skilled nursing, or intermediate care facility or elsewhere.
����� As
used in this subsection, "laboratory and X-ray services" includes HIV
drug resistance testing, including, but not limited to, genotype assays that
have been cleared or approved by the federal Food and Drug Administration,
laboratory developed genotype assays, phenotype assays, and other assays using
phenotype prediction with genotype comparison, for persons diagnosed with HIV
infection or AIDS.
����� b.�� Subject
to the limitations imposed by federal law, by this act, and by the rules and
regulations promulgated pursuant thereto, the medical assistance program may be
expanded to include authorized services within each of the following
classifications:
����� (1)
�Medical care not included in subsection a.(5) above, or any other type of
remedial care recognized under State law, furnished by licensed practitioners
within the scope of their practice, as defined by State law;
����� (2)
�Home health care services;
����� (3)
�Clinic services;
����� (4)
�Dental services;
����� (5)
�Physical therapy and related services;
����� (6)
�Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed
by a physician skilled in diseases of the eye or by an optometrist, whichever
the individual may select;
����� (7)
�Optometric services;
����� (8)
�Podiatric services;
����� (9)
�Chiropractic services;
����� (10)
�Psychological services;
����� (11)
�Inpatient psychiatric hospital services for individuals under 21 years of age,
or under age 22 if they are receiving such services immediately before
attaining age 21;
����� (12)
�Other diagnostic, screening, preventative, and rehabilitative services, and
other remedial care;
����� (13)
�Inpatient hospital services, nursing facility services, and immediate care
facility services for individuals 65 years of age or over in an institution for
mental diseases;
����� (14)
�Intermediate care facility services;
����� (15)
�Transportation services;
����� (16)
�Services in connection with the inpatient or outpatient treatment or care of
substance use disorder, when the treatment is prescribed by a physician and
provided in a licensed hospital or in a narcotic and substance use disorder
treatment center approved by the Department of Health pursuant to P.L.1970,
c.334 (C.26:2G-21 et. seq.) and whose staff includes a medical director, and
limited those services eligible for federal financial participation under Title
XIX of the federal Social Security Act;
����� (17)
�Any other medical care and any other type of remedial care recognized under
State law, specified by the Secretary of the federal Department of Health and
Human Services, and approved by the commissioner;
����� (18)
�Comprehensive maternity care, which may include: the basic number of prenatal
and postpartum visits recommended by the American College of Obstetrics and
Gynecology; additional prenatal and postpartum visits that are medically
necessary; necessary laboratory, nutritional assessment and counseling, health
education, personal counseling, managed care, outreach, and follow-up services;
treatment of conditions which may complicate pregnancy doula care; and
physician or certified nurse midwife delivery services.� For the purposes of
this paragraph, "doula" means a trained professional who provides
continuous physical, emotional, and informational support to a mother before,
during, and shortly after childbirth, to help her to achieve the healthiest, most
satisfying experience possible;
����� (19)
�Comprehensive pediatric care, which may include: ambulatory, preventive, and
primary care health services.� The preventive services shall include, at a
minimum, the basic number of preventive visits recommended by the American
Academy of Pediatrics;
����� (20)
�Services provided by a hospice which is participating in the Medicare program
established pursuant to Title XVIII of the Social Security Act, Pub.L.89-97 (42
U.S.C. s.1395 et seq.).� Hospice services shall be provided subject to approval
of the Secretary of the federal Department of Health and Human Services for
federal reimbursement;
����� (21)
�Mammograms, subject to approval of the Secretary of the federal Department of
Health and Human Services for federal reimbursement, including one baseline
mammogram for women who are at least 35 but less than 40 years of age; one
mammogram examination every two years or more frequently, if recommended by a
physician, for women who are at least 40 but less than 50 years of age; and one
mammogram examination every year for women age 50 and over;
����� (22)
�Upon referral by a physician, advanced practice nurse, or physician assistant
of a person who has been diagnosed with diabetes, gestational diabetes, or
pre-diabetes, in accordance with standards adopted by the American Diabetes
Association:
����� (a)
�Expenses for diabetes self-management education or training to ensure that a
person with diabetes, gestational diabetes, or pre-diabetes can optimize
metabolic control, prevent and manage complications, and maximize quality of
life.� Diabetes self-management education shall be provided by an in-State
provider who is:
����� (i)
�a licensed, registered, or certified health care professional who is certified
by the National Certification Board of Diabetes Educators as a Certified
Diabetes Educator, or certified by the American Association of Diabetes
Educators with a Board Certified-Advanced Diabetes Management credential,
including, but not limited to: a physician, an advanced practice or registered
nurse, a physician assistant, a pharmacist, a chiropractor, a dietitian
registered by a nationally recognized professional association of dietitians,
or a nutritionist holding a certified nutritionist specialist (CNS) credential
from the Board for Certification of Nutrition Specialists; or
����� (ii)
�an entity meeting the National Standards for Diabetes Self-Management
Education and Support, as evidenced by a recognition by the American Diabetes
Association or accreditation by the American Association of Diabetes Educators;
����� (b)
�Expenses for medical nutrition therapy as an effective component of the
person's overall treatment plan upon a: diagnosis of diabetes, gestational
diabetes, or pre-diabetes; change in the beneficiary's medical condition,
treatment, or diagnosis; or determination of a physician, advanced practice
nurse, or physician assistant that reeducation or refresher education is
necessary.� Medical nutrition therapy shall be provided by an in-State provider
who is a dietitian registered by a nationally-recognized professional
association of dietitians, or a nutritionist holding a certified nutritionist
specialist (CNS) credential from the Board for Certification of Nutrition
Specialists, who is familiar with the components of diabetes medical nutrition
therapy;
����� (c)
�For a person diagnosed with pre-diabetes, items and services furnished under
an in-State diabetes prevention program that meets the standards of the
National Diabetes Prevention Program, as established by the federal Centers for
Disease Control and Prevention; and
����� (d)
�Expenses for any medically appropriate and necessary supplies and equipment
recommended or prescribed by a physician, advanced practice nurse, or physician
assistant for the management and treatment of diabetes, gestational diabetes,
or pre-diabetes, including, but not limited to: equipment and supplies for
self-management of blood glucose; insulin pens; insulin pumps and related
supplies; and other insulin delivery devices;
����� (23)
�Expenses incurred for the provision of group prenatal services to a pregnant
woman, provided that:
����� (a)
�the provider of such services, which shall include, but not be limited to, a
federally qualified health center or a community health center operating in the
State:
����� (i)
�is a site accredited by the Centering Healthcare Institute, or is a site
engaged in an active implementation contract with the Centering Healthcare
institute, that utilizes the Centering Pregnancy model; and
����� (ii)
�incorporates the applicable information outlined in any best practices manual
for prenatal and postpartum maternal care developed by the Department of Health
into the curriculum for each group prenatal visit;
����� (b)
�each group prenatal care visit is at least 1.5 hours in duration, with a.
minimum of two women and a maximum of 20 women in participation; and
����� (c)
�no more than 10 group prenatal care visits occur per pregnancy.� As used in
this paragraph, "group prenatal care services" means a series of
prenatal care visits provided in a group setting which are based upon the
Centering Pregnancy model developed by the Centering Healthcare Institute and
which include health assessments, social and clinical support, and educational
activities;
����� (24)
�Expenses incurred for the provision of pasteurized donated human breast milk,
which shall include human milk fortifiers if indicated in a medical order
provided by a licensed medical practitioner, to an infant under the age of six
months; provided that the milk is obtained from a human milk bank that meets
quality guidelines established by the Department of Health and a licensed
medical practitioner has issued a medical order for the infant under at least
one of the following circumstances:
����� (a)
�the infant is medically or physically unable to receive maternal breast milk
or participate in breast feeding, or the infant's mother is medically or
physically unable to produce maternal breast milk in sufficient quantities or
participate in breast feeding despite optimal lactation support; or
����� (b)
�the infant meets any of the following conditions:
����� (i)
�a body weight below healthy levels, as determined by the licensed medical
practitioner issuing the medical order for the infant;
����� (ii)
�the infant has a congenital or acquired condition that places the infant at a
high risk for development of necrotizing enterocolitis; or
����� (iii)
�the infant has a congenital or acquired condition that may benefit from the
use of donor breast milk and human milk fortifiers, as determined by the
Department of Health;
����� (25)
�Comprehensive tobacco cessation benefits to an individual who is 18 years of
age or older, or who is pregnant.� Coverage shall include: brief and high
intensity individual counseling, brief and high intensity group counseling, and
telemedicine as defined by section 1 of P.L.2017, c.117 (C.45:1-61); all
medications approved for tobacco cessation by the U.S. Food and Drug
Administration; and other tobacco cessation counseling recommended by the
Treating Tobacco Use and Dependence Clinical Practice Guideline issued by the
U.S. Public Health Service.� Notwithstanding the provisions of any other law,
rule, or regulation to the contrary, and except as otherwise provided in this
section:
����� (a)
�Information regarding the availability of the tobacco cessation services
described in this paragraph shall be provided to all individuals authorized to
receive the tobacco cessation services pursuant to this paragraph at the
following times: no later than 90 days after the effective date of P.L.2019,
c.473: upon the establishment of an individual's eligibility for medical
assistance; and upon the redetermination of an individual's eligibility for
medical assistance;
����� (b)
�The following conditions shall not be imposed on any tobacco cessation
services provided pursuant to this paragraph: copayments or any other forms of
cost-sharing, including deductibles; counseling requirements for medication;
stepped care therapy or similar restrictions requiring the use of one service
prior to another; limits on the duration of services; or annual or lifetime
limits on the amount, frequency, or cost of services, including, but not
limited to, annual or lifetime limits on the number of covered attempts to
quit; and
����� (c)
�Prior authorization requirements shall not be imposed on any tobacco cessation
services provided pursuant to this paragraph except in the following
circumstances where prior authorization may be required: for a treatment that
exceeds the duration recommended by the most recently published United States
Public Health Service clinical practice guidelines on treating tobacco use and
dependence; or for services associated with more than two attempts to quit
within a 12-month period;
����� (26)
�Provided that there is federal financial participation available, benefits for
expenses incurred in conducting a colorectal cancer screening in accordance
with United States Preventive Services Task Force recommendations.� The method
and frequency of screening to be utilized shall be in accordance with the most
recent published recommendations of the United States Preventive Services Task
Force and as determined medically necessary by the covered person's physician,
in consultation with the covered person.
����� No
deductible, coinsurance, copayment, or any other cost-sharing requirement shall
be imposed for a colonoscopy performed following a positive result on a
non-colonoscopy, colorectal cancer screening test recommended by the United
States Preventive Services Task Force;
����� (27)
�(a) Within 24 months of the effective date of P.L.2023, c.187 (C.30:4D-6u et
al.), and conditional on the receipt of all necessary federal approvals and the
securing of federal financial participation pursuant to section 2 of P.L.2023,
c.187 (C.30:4D-6u), community-based palliative care benefits which shall
include, but not be limited to, all of the following:
����� (i)
�specialized medical care and emotional and spiritual support for beneficiaries
with serious advanced illnesses;
����� (ii)
�relief of symptoms, pain, and stress of serious illness;
����� (iii)
�improvement of quality of life for both the beneficiary and the beneficiary's
family; and
����� (iv)
�appropriate care for any age and for any stage of serious illness, along with
curative treatment.
����� (b)
�Benefits provided under this paragraph shall include, but shall not be limited
to, services provided by a hospice pursuant to paragraph (20) of subsection b.
of this section, provided that:
����� (i)
�hospice services may be provided at the same time that curative treatment is
available, to the extent that services are not duplicative;
����� (ii)
�hospice services may be provided to beneficiaries whose conditions may result
in death, regardless of the estimated length of the beneficiary's remaining
period of life; and
����� (iii)
�the Division of Medical Assistance and Health Services in the Department of
Human Services may include any other service deemed appropriate under the
benefits provided under this paragraph.
����� (c)
�Providers authorized to deliver benefits provided under this paragraph shall
include Medicaid-approved licensed hospice agencies, Medicaid-approved home
health agencies licensed to provide hospice care, and other Medicaid-approved
licensed health care providers.
����� (d)
�Nothing in this paragraph shall be construed to result in the elimination or
reduction of covered benefits or services under the Medicaid program.
����� (e)
�This paragraph shall not affect a beneficiary's eligibility to receive,
concurrently with services provided for in this paragraph, any services,
including home health services, for which the beneficiary would have been
eligible in the absence of this paragraph, to the extent that services are not
duplicative; and
����� (28)
(a) medically necessary treatment for women with a diagnosis of perimenopause,
menopause, and symptoms associated with perimenopause and menopause, including
but not limited to:
����� (i)��
hormonal
therapies such as hormone replacement therapy
[
and
]
, bioidentical
hormone treatments
, and testosterone therapy
;
����� (ii)�
non-hormonal treatments, including medications to manage menopausal symptoms;
����� (iii)������������ �
behavioral health care services;
����� (iv) �
pelvic floor physical therapy;
����� (v)�
bone health treatments, including screenings
and medications due to hormonal changes related to
perimenopause and menopause;
����� (vi) �
preventative services that have a rating of �A� or �B� in the current
recommendations of the United States Preventive Services Task Force for early
detection and treatment of health conditions related to perimenopause and
menopause such as osteoporosis and cancer; and
����� (vii)
�counseling and education regarding menopause management.
���� (b)
�Benefits for testosterone therapy, prescribed pursuant to sub-subparagraph (i)
of subparagraph (a) of this paragraph, shall be provided to the same extent as
for any hormonal treatment under this section and shall not be denied if the
prescribed therapy is not indicated by the federal Food and Drug Administration
to be approved for perimenopause or menopause.
�����
(c)
� Individuals receiving medical assistance shall be
provided with clear and accessible information regarding covered perimenopause
and menopause related treatments.
�����
[
(c)
]
(d)
��� As used in this paragraph:
����� �Menopause�
means the permanent end of a female�s menstrual cycle, diagnosed by a licensed
medical provider after 12 consecutive months without a menstrual period.
����� �Perimenopause�
means the transitional period leading to menopause, marked by fluctuating
hormone levels and changes in menstrual cycles.
����� c.�� Payments
for the foregoing services, goods and supplies furnished pursuant to this act
shall be made to the extent authorized by this act, the rules and regulations
promulgated pursuant thereto and, where applicable, subject to the agreement of
insurance provided for under this act.� The payments shall constitute payment
in full to the provider on behalf of the recipient.� Every provider making a
claim for payment pursuant to this act shall certify in writing on the claim
submitted that no additional amount will be charged to the recipient, the
recipient's family, the recipient's representative or others on the recipient's
behalf for the services, goods, and supplies furnished pursuant to this act.
����� No
provider whose claim for payment pursuant to this act has been denied because
the services, goods, or supplies were determined to be medically unnecessary
shall seek reimbursement form the recipient, his family, his representative or
others on his behalf for such services, goods, and supplies provided pursuant
to this act; provided, however, a provided may seek reimbursement from a
recipient for services, goods, or supplies not authorized by this act, if the
recipient elected to receive the services, goods or supplies with the knowledge
that they were not authorized.
����� d.�� Any
individual eligible for medical assistance (including drugs) may obtain such
assistance from any person qualified to perform the service or services
required (including an organization which provides such services, or arranges
for their availability on a prepayment basis), who undertakes to provide the
individual such services.
����� No
copayment or other form of cost-sharing shall be imposed on any individual
eligible for medical assistance, except as mandated by federal law as a
condition of federal financial participation.
����� e.�� Anything
in this act to the contrary notwithstanding, no payments for medical assistance
shall be made under this act with respect to care or services for any
individual who:
����� (1)
�Is an inmate of a public institution (except as a patient in a medical
institution); provided, however, that an individual who is otherwise eligible
may continue to receive services for the month in which he becomes an inmate,
should the commissioner determine to expand the scope of Medicaid eligibility
to include such an individual, subject to the limitations imposed by federal
law and regulations, or
����� (2)
�Has not attained 65 years of age and who is a patient in an institution for
mental diseases, or
����� (3)
�Is over 21 years of age and who is receiving inpatient psychiatric hospital
services in a psychiatric facility; provided, however, that an individual who
was receiving such services immediately prior to attaining age 21 may continue
to receive such services until the individual reaches age 22.� Nothing in this
subsection shall prohibit the commissioner from extending medical assistance to
all eligible persons receiving inpatient psychiatric services; provided that
there is federal financial participation available.
����� f.
�(1) �A third party as defined in section 3 of P.L.1968, c.413 (C.30:4D-3)
shall not consider a person's eligibility for Medicaid in this or another state
when determining the person's eligibility for enrollment or the provision of
benefits by that third party.
����� (2)
�In addition, any provision in a contract of insurance, health benefits plan,
or other health care coverage document, will, trust, agreement, court order, or
other instrument which reduces or excludes coverage or payment for health
care-related goods and services to or for an individual because of that
individual's actual or potential eligibility for or receipt of Medicaid
benefits shall be null and void, and no payments shall be made under this act
as a result of any such provision.
����� (3)
�Notwithstanding any provision of law to the contrary, the provisions of
paragraph (2) of this subsection shall not apply to a trust agreement that is
established pursuant to 42 U.S.C. s.1396p(d)(4)(A) or (C) to supplement and
augment assistance provided by government entities to a person who is disabled
as defined in section 1614(a)(3) of the federal Social Security Act (42 31
U.S.C. s.1382c (a)(3)).
����� g.�� The
following services shall be provided to eligible medically needy individuals as
follows:
����� (1)
�Pregnant women shall be provided prenatal care and delivery services and
postpartum care, including the services cited in subsections a.(1), (3), and
(5) of this section and subsections b.(1)-(10), (12), (15), and (17) of this
section, and nursing facility services cited in subsection b.(13) of this
section.
����� (2)
�Dependent children shall be provided with services cited in subsections a.(3)
and (5) of this section and subsections b.(1), (2), (3), (4), (5), (6), (7),
(10), (12), (15), and (17) of this section, and nursing facility services cited
in subsection b.(13) of this section.
����� (3)
�Individuals who are 65 years of age or older shall be provided with services
cited in subsections a.(3) and (5) of this section and subsections b.(1)-(5),
(6) excluding prescribed drugs, (7), (8), (10), (12), (15), and (17) of this
section, and nursing facility services cited in subsection b.(13) of this
section.
����� (4)
�Individuals who are blind or disabled shall be provided with services cited in
subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6)
excluding prescribed drugs, (7), (8), (10), 3 (12), (15), and (17) of this
section, and nursing facility services cited in subsection b.(13) of this
section.
����� (5)
�(a) Inpatient hospital services, subsection a.(1) of this section, shall only
be provided to eligible medically needy individuals, other than pregnant women,
if the federal Department of Health and Human Services discontinues the State's
waiver to establish inpatient hospital reimbursement rates for the Medicare and
Medicaid programs under the authority of section 601(c)(3) of the Social
Security Act Amendments of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)).�
Inpatient hospital services may be extended to other eligible medically needy
individuals if the federal Department of Health and Human Services directs that
these services be included.
����� (b)
�Outpatient hospital services, subsection a.(2) of this section, shall only be
provided to eligible medically needy individuals if the federal Department of
Health and Human Services discontinues the State's waiver to establish
outpatient hospital reimbursement rates for the Medicare and Medicaid programs
under the authority of section 601(c)(3) of the Social Security Amendments of
1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)).� Outpatient hospital services may
be extended to all or to certain medically needy individuals if the federal
Department of Health and Human Services directs that these services be
included.� However, the use of outpatient hospital services shall be limited to
clinic services and to emergency room services for injuries and significant
acute medical conditions.
����� (c)
�The division shall monitor the use of inpatient and outpatient hospital
services by medically needy persons.
����� h.�� In
the case of a qualified disabled and working individual pursuant to section
h6408 of Pub.L.101-239 (42 U.S.C. s.1396d), the only medical assistance
provided under this act shall be the payment of premiums for Medicare part A
under 42 U.S.C. ss.1395i-2 and 1395r.
����� i.��� In
the case of a specified low-income Medicare beneficiary pursuant to 42 U.S.C.
s.1396a(a)10(E)iii, the only medical assistance provided under this act shall
be the payment of premiums for Medicare part B under 42 U.S.C. s.1395r as
provided for in 42 U.S.C. s.1396d(p)(3)(A)(ii).
����� j.��� In
the case of a qualified individual pursuant to 42 U.S.C. s.1396a(aa), the only
medical assistance provided under this act shall be payment for authorized
services provided during the period in which the individual requires treatment
for breast or cervical cancer, in accordance with criteria established by the
commissioner.
����� k.�� In
the case of a qualified individual pursuant to 42 U.S.C. s.1396a(ii), the only
medical assistance provided under this act shall be payment for family planning
services and supplies as described at 42 U.S.C. s.1396d(a)(4)(C), including
medical diagnosis and treatment services that are provided pursuant to a family
planning service in a family planning setting.
(cf:
P.L.2025, c.200, s.11)
���� 12.� This act shall take
effect on the 90th day next following the date of enactment and shall apply to
policies and contracts that are delivered, issued, executed or renewed on or
after that date, except that policies and contracts that are delivered, issued
executed, or renewed pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) shall be
effective on January 1, 2027.
STATEMENT
���� This bill clarifies that
testosterone therapy is a covered treatment under the �New Jersey Menopause
Coverage Act.�
���� Under the bill, health
insurance carriers (including insurance companies, hospital service
corporations, medical service corporations, health service corporations, and health
maintenance organizations authorized to issue health benefits plans in New
Jersey, entities contracted to administer health benefits in connection with
the State Health Benefits Program and School Employees� Health Benefits
Program, and the New Jersey FamilyCare Program) will be required to cover, as
part of their coverage of medically necessary perimenopause and menopause treatments
under the �New Jersey Menopause Coverage Act,� testosterone therapy.� The bill
also requires that benefits for the prescribed testosterone therapy be provided
to the same extent as for any other hormonal treatment under the bill, and
stipulates that prescribed testosterone therapy will not be denied by a carrier
if the therapy is not indicated by the federal Food and Drug Administration to
be approved for perimenopause or menopause.