Requires unrestricted Medicaid coverage for ovulation enhancing drugs and medical services related to administering such drugs for certain beneficiaries experiencing infertility.
What changed between versions
The bill was transformed from a single-purpose infertility drug coverage measure into a full rewrite of Section 6 of the Medicaid statute, incorporating all existing mandatory and optional benefit categories plus many new ones. This changes the bill from a targeted policy fix to a comprehensive Medicaid benefits expansion.
New optional Medicaid benefit added for perimenopause and menopause treatment, including hormone replacement therapy, bioidentical hormones, non-hormonal medications, behavioral health services, pelvic floor physical therapy, bone health treatments, USPSTF A/B-rated preventative services, and counseling/education.
New optional Medicaid benefit for comprehensive tobacco cessation services for adults 18+ or pregnant individuals, including FDA-approved medications, individual and group counseling, and telemedicine. No cost-sharing allowed; prior authorization limited to treatments exceeding guideline duration or more than two quit attempts in 12 months.
New optional Medicaid benefit for group prenatal care services using the Centering Pregnancy model, with visits of at least 1.5 hours, groups of 2-20 women, and a maximum of 10 visits per pregnancy.
New optional Medicaid benefit for pasteurized donated human breast milk (with fortifiers if medically indicated) for infants under 6 months who cannot receive maternal breast milk or meet specific clinical criteria such as low body weight or high risk for necrotizing enterocolitis.
New optional Medicaid benefit for colorectal cancer screening per USPSTF recommendations, with no cost-sharing for colonoscopy following a positive non-colonoscopy screening test.
New optional Medicaid benefit for community-based palliative care including specialized medical, emotional, and spiritual support for beneficiaries with serious advanced illnesses, available concurrently with curative treatment. Must be implemented within 24 months of P.L.2023, c.187 effective date.
New optional Medicaid benefit for comprehensive maternity care including doula care (defined as a trained professional providing continuous physical, emotional, and informational support before, during, and after childbirth), additional medically necessary prenatal/postpartum visits, and treatment of pregnancy complications.
New optional Medicaid benefit for diabetes self-management education, medical nutrition therapy, CDC-recognized diabetes prevention programs for pre-diabetes, and supplies/equipment including insulin pens, pumps, and blood glucose monitoring devices.
New optional Medicaid benefit for mammograms with specific frequency: one baseline at age 35-39, every two years (or more frequently if physician-recommended) at age 40-49, and annually at age 50 and over.
The ovulation enhancing drug provision (now paragraph 29) was clarified to specify covered drugs include oral versions of clomiphene, bromocriptine, letrozole, tamoxifen, and any other oral ovulation enhancing drug for which the Division receives federal financial participation. The commissioner may revise the list conditional on federal approval.
The definition of infertility for ovulation drug coverage now includes an explicit non-discrimination clause: 'Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.'
Effective date changed from the first day of the fourth month following enactment to the first day of the twelfth month following enactment, giving the state a full year for implementation.
Section 2 now explicitly states that provision of services under the act is contingent upon receipt of all necessary federal approvals and federal financial participation, making the entire benefits expansion conditional on federal Medicaid funding.
New subsections c through l add payment rules (payment in full to provider, no balance billing), a prohibition on cost-sharing except as mandated by federal law, exclusions for inmates and certain institutionalized patients, third-party liability protections preventing insurers from denying coverage based on Medicaid eligibility, and specific service levels for medically needy individuals by category.
