AN ACT EXPANDing ACCESS TO AFFORDABLE, COMPREHENSIVE HEALTHCARE FOR WOMEN IN MIDLIFE THROUGH IMPROVED health insurance and medicaid COVERAGE; programs to expand access to essential midlife healthcare services; tax credits for individuals and businesses for midlife healthcare expenses; EXPANDED ACCESS TO PROVIDERS TRAINED IN essential MIDLIFE HEALTHcare services; public awareness and outreach; better data collection and oversight; establishment of a midlife health advisory council; and appropriating funds for these purposes.

Whereas, women in midlife (ages 40‑65) face unique healthcare challenges, including menopause‑related conditions, increased risk of chronic diseases, and barriers to affordable healthcare access; and

Whereas, improving access to midlife healthcare services will enhance quality of life, reduce long‑term healthcare costs, and promote preventive care for women in North Carolina; and

Whereas, it is the policy of the State of North Carolina to promote public health and equitable healthcare access; Now, therefore,

The General Assembly of North Carolina enacts:

PART I. TITLE

SECTION 1.1.  This act shall be known as The Thrive at Midlife Act.

part II. definitions

SECTION 2.1.  The following definitions apply in this act:

(1)        Essential midlife healthcare services. – Includes, but is not limited to, all of the following:

a.         Menopause‑related care and hormone therapy.

b.         Osteoporosis screenings.

c.         Cardiovascular disease prevention.

d.         Diabetes screenings and management.

e.         Mammograms and cervical cancer screenings.

f.          Mental health and wellness programs.

g.         Telehealth services for midlife‑specific conditions.

(2)        Midlife women. – Individuals assigned female at birth or who identify as women and who are at least 40 but less than 65 years of age.

PART III. Expanded coverage REQUIREMENTS

INSURANCE MANDATES

SECTION 3.1.(a)  Article 3 of Chapter 58 of the General Statutes is amended by adding a new section to read:

§ 58‑3‑305.  Coverage required for essential midlife healthcare services.

(a)        All health benefit plans shall include coverage for essential midlife healthcare services for individuals who either (i) were assigned female at birth or (ii) identify as a woman and who are at least 40 years of age but less than 65 years of age.

(b)        Essential midlife healthcare services required to be covered under this section include all of the following:

(1)        Menopause‑related care and hormone therapy.

(2)        Osteoporosis screenings.

(3)        Cardiovascular disease prevention.

(4)        Diabetes screening and management.

(5)        Mammograms and cervical cancer screenings.

(6)        Mental health and wellness programs.

(7)        Telehealth services for midlife‑specific conditions.

(c)        Any cost‑sharing requirements, including copayments and deductibles, for essential midlife healthcare services shall not exceed those established for preventative services under the Patient Protection and Affordable Care Act, P.L. 111‑148, as amended, or other applicable federal law.

SECTION 3.1.(b)  The Department of Health and Human Services, Division of Health Benefits, shall ensure coverage for essential midlife healthcare services, as described in G.S. 58‑3‑305(b), for Medicaid recipients who either (i) were assigned female at birth or (ii) identify as a woman and who are at least 40 years of age but less than 65 years of age.

SECTION 3.1.(c)  Subsection (a) of this section is effective October 1, 2025, and applies to insurance contracts issued, renewed, or amended on or after that date. The remainder of this section is effective when it becomes law.

MIDLIFE HEALTH ACCESS PROGRAM

SECTION 3.2.(a)  Effective July 1, 2025, there is appropriated from the General Fund to the Department of Health and Human Services, Division of Central Management and Support, Office of Rural Health (ORH), the sum of ten million dollars ($10,000,000) in recurring funds for each year of the 2025‑2027 fiscal biennium to establish a Midlife Health Access Grant Program (Program). The purpose of the Program is to provide directed grants on a competitive basis to federally qualified health centers, rural health clinics, community‑based nonprofit organizations, and other safety‑net providers that are capable of providing essential midlife healthcare services to midlife women who are uninsured regardless of their ability to pay.

SECTION 3.2.(b)  The ORH shall develop application materials and selection criteria for the Program. The selection criteria shall take into consideration the availability of other funds available to the grantee and the incidence of poverty in the area served by the grantee. The ORH shall make the final decision about awarding grants under this Program, subject to the following requirements and limitations:

(1)        The ORH shall give priority to applicants located in rural and underserved areas of the State.

(2)        The maximum amount of a grant award under the Program is one hundred thousand dollars ($100,000) per grantee.

SECTION 3.2.(c)  The ORH may use up to five percent (5%) of these allocated funds to pay for administrative costs associated with establishing and administering the Program.

SECTION 3.2.(d)  Annually by April 1, beginning April 1, 2027, the ORH shall report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division on the Program authorized by this section. The report shall include at least all of the following information regarding the preceding fiscal year:

(1)        A detailed breakdown of expenditures for the Program.

(2)        The identity and a brief description of each grantee and the amount of funding awarded to each grantee.

(3)        The number of people served by each grantee.

(4)        Any other information the Department deems relevant in evaluating the success of the Program.

part iV. financial relief measures

MIDLIFE HEALTHCARE INDIVIDUAL TAX CREDIT AND BUSINESS TAX CREDIT

SECTION 4.1.(a)  Article 4 of Chapter 105 of the General Statutes is amended by adding two new sections to read:

§ 105‑153.12.  Midlife healthcare individual tax credit.

(a)        Definitions. – The following definitions apply in this section:

(1)        FDA. – The United States Food and Drug Administration.

(2)        Expenses for midlife healthcare. – Expenses for any of the following:

a.         Menopause‑related treatments, including hormone therapy, prescription medications, and medically recommended non‑hormonal alternatives.

b.         Preventative health screenings, including mammograms, cervical cancer screenings, osteoporosis screenings, and cardiovascular risk assessments.

c.         Chronic disease management, including treatment of diabetes, hypertension, cholesterol issues, and other midlife‑onset chronic conditions.

d.         Mental health services, including therapy or counseling related to midlife hormonal changes, menopause‑induced anxiety, and depression.

e.         Telehealth visits conducted for a treatment, screening, or service under sub‑subdivisions a. through d. of this subdivision.

(3)        Expenses for menopause treatment. – Expenses for any FDA‑approved therapy, medication, or intervention prescribed by a licensed physician for managing menopause symptoms, including the following:

a.         Hormone replacement therapy.

b.         Non‑hormonal prescription treatments.

c.         Prescription vaginal estrogen treatments.

(4)        Expenses for prescription medications. – Expenses for FDA‑approved prescription medications that directly address midlife health concerns, including osteoporosis, cardiovascular health, menopause, and diabetes.

(5)        Out‑of‑pocket expenses. – The total of the following expenses that are not reimbursed by health insurance:

a.         Expenses for midlife healthcare.

b.         Expenses for menopause treatment.

c.         Expenses for prescription medications.

(b)        Credit. – A taxpayer who has out‑of‑pocket expenses is allowed a credit against the tax imposed by this Part equal to a percentage of the taxpayer's out‑of‑pocket expenses listed in the table below and based upon the taxpayer's filing status and adjusted gross income, as calculated under the Code:

Filing Status                                       AGI                                    Credit Amount

Married, filing jointly                   Up to $100,000                               100%

                                                      Over $100,000

                                                      Up to $200,000                                 50%

                                                      Over $200,000                                    0%

Head of Household                       Up to $100,000                               100%

                                                      Over $100,000

                                                      Up to $200,000                                 50%

                                                      Over $200,000                                    0%

Single                                            Up to $100,000                               100%

                                                      Over $100,000                                    0%

Married, filing separately              Up to $100,000                               100%

                                                      Over $100,000                                    0%.

(c)        Credit Refundable. – If the credit allowed by this section exceeds the amount of tax imposed by this Part for the taxable year reduced by the sum of all credits allowable, the Secretary must refund the excess to the taxpayer. The refundable excess is governed by the provisions governing a refund of an overpayment by the taxpayer of the tax imposed by this Part. In computing the amount of tax against which multiple credits are allowed, nonrefundable credits are subtracted before refundable credits.

§ 105‑153.13.  Midlife healthcare business tax credit.

(a)        Definitions. – The definitions in G.S. 105‑153.12 and the following definitions apply in this section:

(1)        Eligible business. – A business with a physical presence in the State that has out‑of‑pocket expenses.

(2)        Out‑of‑pocket expenses. – As defined in G.S. 105‑153.12 and paid by an eligible business on behalf of a qualifying employee.

(3)        Qualifying employee. – An individual employed (i) for consideration for at least 35 hours a week and whose wages are subject to withholding under Article 4A of Chapter 105 of the General Statutes and (ii) by an eligible business.

(b)        Credit. – A taxpayer who is an eligible business and has out‑of‑pocket expenses is allowed a credit against the tax imposed by this Part equal to ten percent (10%) of the taxpayer's total out‑of‑pocket expenses.

(c)        Credit Refundable. – If the credit allowed by this section exceeds the amount of tax imposed by this Part for the taxable year reduced by the sum of all credits allowable, the Secretary must refund the excess to the taxpayer. The refundable excess is governed by the provisions governing a refund of an overpayment by the taxpayer of the tax imposed by this Part. In computing the amount of tax against which multiple credits are allowed, nonrefundable credits are subtracted before refundable credits.

(d)       Aggregate Limitation. – The total amount of credits allowed pursuant to this section may not exceed in the aggregate five million dollars ($5,000,000) for all taxpayers for any one calendar year.

(e)        Application. – An eligible business seeking to claim a tax credit provided for under this section shall submit an application to the Department of Revenue for tentative approval for the tax credit in the year for which the tax credit is claimed or allowed. Applications shall be accepted on a first come, first served basis. The Department of Revenue shall provide for the manner in which the application is to be submitted and the information required in the application which shall include, at a minimum, proof of the applicant business's out‑of‑pocket expenses. The Department of Revenue shall review the application and tentatively shall approve the application upon determining that it meets the requirements of this section by January 31 of the year after the application was submitted. If the credit amounts on the tax credit applications filed with the Department of Revenue exceed the maximum aggregate limit of tax credits, then the tax credit must be allocated among the eligible business entities who filed a timely application on a first come, first served basis based upon the amounts otherwise allowed by this section. Once the tax credit application has been approved and the amount has been communicated to the applicant, the eligible business then may apply the amount of the approved tax credit to its tax liability for the tax year of which the approved application applies.

(f)        Report. – By March 31 of each year, the Department of Revenue shall report to the Joint Legislative Committee on Governmental Operations by county, the number of eligible business tax credit applications the Department has received, the number of tax credit applications approved, and the tax credits approved. This report must be made available in a conspicuous place on the Department's website.

SECTION 4.1.(b)  This section is effective for taxes imposed for taxable years beginning on or after January 1, 2025.

THRIVE AT MIDLIFE GRANT PROGRAM FOR SMALL BUSINESS

SECTION 4.2.(a)  Creation; Administration. – The Thrive at Midlife Grant Program (Program) is established and shall be administered by the Department of Health and Human Services in accordance with this section.

SECTION 4.2.(b)  Purpose. – The purpose of the program is to promote access to and support for midlife healthcare by providing financial assistance in the form of grants to eligible businesses who have out‑of‑pocket expenses.

SECTION 4.2.(c)  Definitions. – The following definitions apply in this section:

(1)        Department. – The Department of Health and Human Services.

(2)        Eligible business. – A business with a physical presence in the State that (i) has its headquarters located in this State, (ii) employs 50 or fewer people in this State, (iii) has out‑of‑pocket expenses during the taxable year in which it applies for grant funding under this section, and (iv) submits proof of its out‑of‑pocket expenses on a form and in a manner approved by the Department.

(3)        Expenses for menopause treatment. – Expenses for any FDA approved therapy, medication, or intervention prescribed by a licensed physician for managing menopause symptoms, including the following:

a.         Hormone replacement therapy.

b.         Non‑hormonal prescription treatments.

c.         Prescription vaginal estrogen treatments.

(4)        Expenses for midlife healthcare. – Expenses for any of the following:

a.         Menopause related treatments, including hormone therapy, prescription medications, and medically recommended non‑hormonal alternatives.

b.         Preventative health screenings, including mammograms, cervical cancer screenings, osteoporosis screenings, and cardiovascular risk assessments.

c.         Chronic disease management, including treatment of diabetes, hypertension, cholesterol issues, and other midlife onset chronic conditions.

d.         Mental health services, including therapy or counseling related to midlife hormonal changes, menopause induced anxiety, and depression.

e.         Telehealth visits conducted for a treatment, screening, or service under sub‑subdivisions a. through d. of this subdivision.

(5)        Expenses for prescription medications. – Expenses for FDA approved prescription medications that directly address midlife health concerns, including osteoporosis, cardiovascular health, menopause, and diabetes.

(6)        FDA. – The United States Food and Drug Administration.

(7)        Out‑of‑pocket expenses. – The total of the following:

a.         Expenses for midlife healthcare.

b.         Expenses for menopause treatment.

c.         Expenses for prescription medications.

(8)        Program. – The Thrive at Midlife Grant Program created by this section.

SECTION 4.2.(d)  Eligibility. – Eligible businesses are eligible to apply for a grant from the program.

SECTION 4.2.(e)  Application; Limitations. – An eligible business must apply to the Department for a grant during the time frame and on a form prescribed by the Department and must include any supporting documentation required by the Department. Grants shall be awarded on a first come, first served basis. The grant amount to an eligible business may not exceed two thousand five hundred dollars ($2,500) per year. The total of all grants awarded under the program may not exceed the total amount of funds appropriated to and otherwise available under the program. The Department shall verify that the applicant is an eligible business prior to awarding any grant funds under the program.

SECTION 4.2.(f)  Administration. – The Department may use up to three percent (3%) of funds appropriated to or otherwise available under the program for administrative purposes.

SECTION 4.2.(g)  Audits. – The Department, in consultation with the Department of Revenue, shall conduct random audits of eligible businesses that receive grant funding under the program. The timing, form, and manner of the audits required by this subsection are in the discretion of the Department but shall be conducted in such a manner as to reasonably ensure that grant funds are used by eligible businesses for purposes consistent with this section.

SECTION 4.2.(h)  There is appropriated from the General Fund to the Department of Health and Human Services the sum of one million dollars ($1,000,000) in nonrecurring funds for the 2025‑2026 fiscal year to be used by the Department for purposes consistent with Section 5.2 of this act.

SECTION 4.2.(i)  This section becomes effective July 1, 2025.

part v. expanded access to providers trained in midlife health

SPECIALIZED TRAINING/MIDLIFE HEALTH FELLOWSHIP PROGRAMS

SECTION 5.1.(a)  G.S. 116‑11 is amended by adding the following new subdivision to read:

(13c)  The Board of Governors shall require each school of medicine affiliated with a constituent institution of The University of North Carolina to separately establish a midlife health fellowship program. The programs shall meet at least the following criteria:

a.         Provide educational opportunities for healthcare providers in menopause and chronic disease care.

b.         Ensure that educational opportunities provided pursuant to sub‑subdivision a. of this subdivision comply with requirements necessary for attendees to receive appropriate credit for continuing medical education.

SECTION 5.1.(b)  No later than July 1, 2026, each school of medicine affiliated with a constituent institution of The University of North Carolina, including the School of Medicine of the University of North Carolina at Chapel Hill and the Brody School of Medicine of East Carolina University, shall establish a midlife health fellowship program in accordance with G.S. 116‑11(13c), as enacted by this act.

EXPANSION OF ACCESS TO MIDLIFE HEALTH PROVIDERS THROUGH TELEHEALTH SERVICES

SECTION 5.2.  Effective July 1, 2025, Section 9B.7A(b) of S.L. 2023‑134 reads as rewritten:

SECTION 9B.7A.(b)  The ORH shall establish a telehealth infrastructure grant program to award grants on a competitive basis to rural healthcare providers to be used to purchase equipment, high‑speed internet access, and any other infrastructure necessary to establish telehealth services, defined as the use of two‑way, real‑time interactive audio and video where the healthcare provider and the patient can hear and see each other. In awarding grants under this program, the ORH is subject to the following requirements and limitations:

(1)        Priority shall be given to independent practices that provide essential midlife healthcare services to individuals assigned female at birth or who identify as women and who are at least 40 but less than 65 years of age; independent primary care practices and practices; and independent obstetrics and gynecology practices. As used in this subdivision, the term essential midlife healthcare services includes one or more of the following:

a.         Menopause‑related care and hormone therapy.

b.         Osteoporosis screenings.

c.         Cardiovascular disease prevention.

d.         Diabetes screenings and management.

e.         Mammograms and cervical cancer screenings.

f.          Mental health and wellness programs.

g.         Telehealth services for midlife‑specific conditions.

(2)        The maximum amount of a grant award is two hundred fifty thousand dollars ($250,000) per grantee.

REGIONAL MIDLIFE HEALTH HUBS PILOT PROGRAM

SECTION 5.3.(a)  Not later than October 1, 2025, the ORH shall establish and administer a Regional Midlife Health Hubs Pilot Program (Pilot Program). The purpose of the Pilot Program is to evaluate the effectiveness of utilizing a community hub accessible in person, through the World Wide Web, or through any other means of electronic access, to refer midlife women to community‑based, essential midlife healthcare services. The Pilot Program shall operate in the five North Carolina counties with the highest healthcare disparities among midlife women. Each participating county shall establish a Regional Midlife Health Hub responsible for implementing and administering the Pilot Program on behalf of the residents of that county. The Pilot Program authorized by this subsection shall terminate upon the filing of the report required by subsection (d) of this section.

SECTION 5.3.(b)  Effective July 1, 2025, there is appropriated from the General Fund to the Department of Health and Human Services, Division of Central Management, Office of Rural Health (ORH), the sum of two million six hundred twenty‑five thousand dollars ($2,625,000) in nonrecurring funds for each year of the 2025‑2027 fiscal biennium to fund establishment and operation of the Pilot Program authorized by subsection (a) of this section. Funds appropriated pursuant to this subsection shall be allocated equally among the five Regional Midlife Health Hubs responsible for implementing and administering the Pilot Program on behalf of the residents of their respective counties.

SECTION 5.3.(c)  Each Regional Midlife Health Hub may use up to five percent (5%) of its allocated funds for each year of the 2025‑2027 fiscal biennium to pay for administrative costs associated with designing, implementing, and administering a community hub to serve the residents of that county.

SECTION 5.3.(d)  By February 1, 2028, the Department of Health and Human Services shall conduct a comprehensive evaluation of the Pilot Program authorized by subsection (a) of this section and submit a report of its findings and recommendations to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division. The report shall include, at a minimum, all of the following information for each Regional Midlife Health Hub:

(1)        A detailed breakdown of expenditures for the Pilot Program.

(2)        A description of the design and operation of each Regional Midlife Health Hub.

(3)        The number of people served by each Regional Midlife Health Hub.

(4)        Any other information the Department deems relevant to determining the success of the Pilot Program.

part vi. public awareness and outreach

STATEWIDE AWARENESS CAMPAIGN

SECTION 6.1.  Effective July 1, 2025, there is appropriated from the General Fund to the Department of Health and Human Services the sum of five hundred thousand dollars ($500,000) in nonrecurring funds for the 2025‑2026 fiscal year to launch a statewide educational and public awareness campaign on health challenges for midlife women and available resources and services to address these challenges. The campaign shall include outreach initiatives conducted through digital media, social media, radio, and television, with materials distributed to the public in English and Spanish.

COMMUNITY PARTNERSHIPS

SECTION 6.2.(a)  Effective July 1, 2025, there is appropriated from the General Fund to the Department of Health and Human Services the sum of two million dollars ($2,000,000) in nonrecurring funds for each year of the 2025‑2027 fiscal biennium to provide grants on a competitive basis to local, nonprofit, and faith‑based organizations that partner with the Department of Health and Human Services to conduct culturally competent outreach and education about health challenges for midlife women and available resources and services to address these challenges.

SECTION 6.2.(b)  Annually by April 1, 2027, and April 1, 2028, the ORH shall report to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division on use of the funds appropriated by this section. The report shall include at least all of the following information regarding the preceding fiscal year:

(1)        A detailed breakdown of expenditures.

(2)        The identity and a brief description of each grantee and the amount of funding awarded to each grantee.

(3)        A description of the outreach and education performed by each grantee, the audience of people receiving such outreach and education, and the geographic location where the outreach and education was performed.

part vii. DATA COLLECTION & OVERSIGHT

ANNUAL REPORTING

SECTION 7.1.  Annually by February 1, beginning February 1, 2027, the Department of Health and Human Services shall compile an annual Midlife Health Report identifying gaps in health insurance coverage for essential midlife healthcare services and evaluating healthcare disparities among midlife women residing in the State. The report shall be submitted to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division and made publicly available on the Department's website.

MIDLIFE HEALTH ADVISORY COUNCIL

SECTION 7.2.(a)  Article 1B of Chapter 130A of the General Statutes is amended by adding new sections to read:

§ 130A‑33.45.  Midlife Health Advisory Council; creation; duties; composition.

(a)        There is established the Midlife Health Advisory Council in the Department. The Council shall have the following duties and responsibilities:

(1)        To make recommendations to the Governor and the Secretary aimed at improving the health status of midlife women, defined as individuals residing in North Carolina who were assigned female at birth or identify as women and who are at least 40 but less than 65 years of age.

(2)        To identify and examine the limitations and problems associated with existing laws, regulations, programs, and services related to the health status of midlife women.

(3)        To examine the financing and access to health services for midlife women.

(4)        To identify and review health promotion and disease prevention strategies relating to the leading causes of death and disability among midlife women.

(5)        To advise the Governor and the Secretary upon any matter which the Governor or Secretary may refer to it.

§ 130A‑33.46.  Midlife Health Advisory Council; members; selection; quorum; compensation.

(a)        The Midlife Health Advisory Council in the Department shall consist of 9 members, to be appointed as follows:

(1)        Five members shall be appointed by the Governor. Members appointed by the Governor shall be representatives of the following groups: healthcare professionals, public health experts, community advocates, and midlife women with lived experience.

(2)        Two members shall be appointed by the Speaker of the House of Representatives, one of whom shall be a member of the House of Representatives, and one of whom shall be a public member or a representative of any of the groups specified in subdivision (1) of this subsection.

(3)        Two members shall be appointed by the President Pro Tempore of the Senate, one of whom shall be a member of the Senate, and one of whom shall be a public member or a representative of any of the groups specified in subdivision (1) of this subsection.

(4)        Of the members appointed by the Governor, two shall serve initial terms of one year, two shall serve initial terms of two years, and one shall serve an initial term of three years. Thereafter, the Governor's appointees shall serve terms of four years.

(5)        Of the nonlegislative members appointed by the Speaker of the House of Representatives, one shall serve an initial term of two years. Thereafter, nonlegislative members appointed by the Speaker of the House of Representatives shall serve terms of four years. Of the nonlegislative members appointed by the President Pro Tempore of the Senate, one shall serve an initial term of two years. Thereafter, nonlegislative members appointed by the President Pro Tempore of the Senate shall serve terms of four years. Legislative members of the Council shall serve two‑year terms.

(b)        The Chairperson of the Council shall be elected by the Council from among its membership.

(c)        The majority of the Council shall constitute a quorum for the transaction of business.

(d)       Members of the Council shall receive per diem and necessary travel and subsistence expenses in accordance with the provisions of G.S. 138‑5 or G.S. 138‑6, or travel and subsistence expenses in accordance with the provisions of G.S. 120‑3.1, as applicable.

(e)        All clerical support and other services required by the Council shall be provided by the Department.

SECTION 7.2.(b)  There is appropriated from the General Fund to the Department of Health and Human Services the sum of two hundred fifty thousand dollars ($250,000) in recurring funds for each year of the 2025‑2027 fiscal biennium to be allocated to cover the operating expenses of the Midlife Health Advisory Council authorized by subsection (a) of this section.

part viii. severability

SECTION 8.1.  If any section or provision of this act is declared unconstitutional or invalid by the courts, it does not affect the validity of this act as a whole or any part other than the part declared to be unconstitutional or invalid.

part ix. effective date

SECTION 9.1.  Except as otherwise provided, this act is effective when it becomes law.