Summary — A5278 (New Jersey Menopause Coverage Act)
Status & procedural history
- Introduced: February 10, 2025 (Assembly).
- Passed Assembly: June 30, 2025 (79–0–0).
- Referred to Senate Budget and Appropriations Committee: October 20, 2025.
- Committee activity: Reported out of Assembly Health, Financial Institutions & Insurance, and Appropriations Committees with amendments. Companion: S4148. Prior-session related bill: A9427. Primary sponsors: Assemblywoman Heather Simmons and Assemblywoman Michaelle C. Solages.
Purpose
- Establishes the "New Jersey Menopause Coverage Act" to require health insurance coverage of medically necessary treatments for perimenopause and menopause and their associated symptoms.
Who is covered / affected
- Insured individuals (women) diagnosed with perimenopause or menopause and covered under plans issued or renewed in New Jersey, including:
- Commercial carriers (insurance companies, HMOs),
- Hospital, medical and health service corporations,
- Plans administered in connection with the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP),
- NJ FamilyCare (New Jersey’s Medicaid program).
- Employers, local governments, and school districts participating in SHBP/SEHBP may see cost impacts.
Key provisions
- Requires coverage (to the same extent as for other medical conditions) for medically necessary treatments for perimenopause, menopause, and associated symptoms, including (but not limited to):
- Hormonal therapies (e.g., hormone replacement therapy, bioidentical hormone treatments);
- Non‑hormonal pharmacologic treatments for symptoms;
- Behavioral health services;
- Pelvic floor physical therapy;
- Bone health treatments (screenings and medications; committee amendments removed “supplements” from covered bone treatments);
- Preventive services for early detection/treatment of related conditions (limited by amendment to services that currently have an “A” or “B” rating from the U.S. Preventive Services Task Force);
- Counseling and education on menopause management.
- Carriers must provide clear, accessible information to covered persons about covered perimenopause and menopause treatments.
- Definitions: “Menopause” is defined as the permanent end of menstrual cycles diagnosed after 12 consecutive months without a period; “Perimenopause” as the transitional period leading to menopause.
Notable committee amendments
- Clarified coverage applies to women with a diagnosis of perimenopause or menopause and associated symptoms.
- Removed supplements from the list of covered bone health treatments.
- Limited covered preventive services to those with current USPSTF “A” or “B” recommendations.
- Set the effective date for individual market policies under the Individual Health Coverage Program to January 1, 2027 (other coverage timing tied to the bill’s enactment language).
Fiscal impact
- Office of Legislative Services (OLS) estimates indeterminate annual expenditure increases for the State (SHBP-State, NJ FamilyCare) and certain local entities (SHBP-Local, SEHBP). Any increased NJ FamilyCare spending would likely generate additional federal Medicaid reimbursement (increasing State revenue).
- OLS cites uncertainty driven by the number of enrollees seeking treatment, utilization management and cost‑sharing policies, and negotiated provider/drug costs. Reference data: women potentially seeking treatment comprised about 7–17% of NJ’s population (Plan Year 2023); an industry analysis found average allowed monthly per‑member costs 23% higher for HRT and 12% higher for non‑hormonal menopause therapy compared with peers not receiving treatment.
Effect on existing coverage
- The mandate applies to contracts issued, renewed, or approved on or after the bill’s effective date(s), and requires parity in benefit provision relative to other medical conditions.
