AN ACT supporting the advancement of menopause research and continuing medical education regarding menopause and menopause‑related care; requiring medicaid and HEALTH INSURANCE COVERAGE OF menopause‑related care; ENACTing PROTECTIONS AGAINST EMPLOYMENT DISCRIMINATION ON ACCOUNT OF MENOPAUSE; and appropriating funds for implementation.

The General Assembly of North Carolina enacts:

part i. advancement of menopause research

SECTION 1.1.(a)  Definitions. – The following definitions apply in this Part:

(1)        Menopause. – The point in time defined as 12 consecutive months after the last menstrual period.

(2)        Menopause‑related care. – Medical, behavioral health, and supportive services addressing symptoms associated with perimenopause, menopause, and postmenopause, including, but not limited to, hormonal and non‑hormonal treatments.

(3)        Perimenopause. – The transitional period during which the body experiences a natural decline in reproductive hormones, resulting in the end of menstrual cycles. This transition typically lasts four to eight years but may last longer than a decade.

(4)        Postmenopause. – The life stage following menopause.

SECTION 1.1.(b)  Comprehensive Evaluation of Current Research. – The Department of Health and Human Services (DHHS) shall conduct a comprehensive evaluation of the current state of research regarding menopause‑related care. In conducting this evaluation, the DHHS shall determine and analyze at least all of the following:

(1)        Existing gaps in scientific knowledge and understanding regarding the etiology, symptomatology, and clinical management of perimenopause, menopause, and postmenopause.

(2)        Clinical and other barriers to the timely diagnosis and effective treatment of menopause.

(3)        Current availability, safety, and clinical efficacy of existing pharmacological and non‑pharmacological therapies for menopause.

(4)        The extent and adequacy of peer‑reviewed research specifically focused on individuals undergoing the menopausal transition.

(5)        Existing gaps in the curricula and continuing medical education of healthcare providers concerning menopause management and patient care.

(6)        Analysis of the disproportionate physical, mental, and socioeconomic impacts of perimenopause, menopause, and postmenopause on underserved and vulnerable populations, including the following:

a.         Black women.

b.         Individuals who identify as LGBTQ+.

c.         Neurodivergent individuals.

d.         Individuals of lower socioeconomic status.

e.         Incarcerated individuals.

SECTION 1.1.(c)  Data Collection. – The DHHS shall collect data on the percentage of North Carolinians experiencing menopause‑related symptoms across the following five decennial age groups:

(1)        Ages 20‑29.

(2)        Ages 30‑39.

(3)        Ages 40‑49.

(4)        Ages 50‑59.

(5)        Ages 60‑69.

SECTION 1.1.(d)  Statewide Strategic Plan. – The DHHS shall develop a statewide strategic plan based on the evaluation conducted pursuant to subsection (b) of this section and the data collected pursuant to subsection (c) of this section to accomplish all of the following:

(1)        To address identified gaps in scientific knowledge and understanding regarding the etiology, symptomatology, and clinical management of perimenopause, menopause, and postmenopause.

(2)        To promote equitable access to menopause‑related care.

(3)        To identify priorities for future clinical and public health research specifically focused on the transition from perimenopause through postmenopause.

SECTION 1.1.(e)  Reporting Requirement. – By December 1, 2027, the DHHS shall submit a report of its activities under this section to the Joint Legislative Oversight Committee on Health and Human Services and the Fiscal Research Division. The report shall include at least all of the following:

(1)        The findings and recommendations of the comprehensive evaluation conducted pursuant to subsection (b) of this section.

(2)        The data collected pursuant to subsection (c) of this section.

(3)        The statewide strategic plan developed pursuant to subsection (d) of this section.

SECTION 1.1.(f)  Appropriations. – There is appropriated from the General Fund to the Department of Health and Human Services, Division of Public Health, the sum of five million dollars ($5,000,000) in nonrecurring funds for the 2026‑2027 fiscal year to be allocated and used as follows:

(1)        To complete the comprehensive evaluation, data collection, strategic planning, and reporting required by this section.

(2)        To design, coordinate, and oversee a statewide menopause education and awareness campaign.

(3)        To promote and support healthcare provider training and continuing medical education initiatives that improve healthcare provider competency in menopause‑related care and expand access to menopause‑related care.

SECTION 1.1.(g)  Effective Date. – This Part becomes effective July 1, 2026.

part ii. continuing medical education incentives

SECTION 2.1.(a)  As used in this section, the term qualifying physician means a physician licensed to practice in this State who meets both of the following criteria:

(1)        Specializes in internal medicine, family medicine, obstetrics and gynecology, cardiology, endocrinology, neurology, or psychiatry.

(2)        Has a patient base that is at least twenty‑five percent (25%) adult women under age 65.

SECTION 2.1.(b)  For the period beginning July 1, 2026, and ending June 30, 2032, qualifying physicians subject to the continuing medical education (CME) requirements of Chapter 90 of the General Statutes shall receive two hours of CME credit for each hour of CME completed in perimenopausal, menopausal, or postmenopausal care. This double credit incentive is available for up to eight hours of CME completed during the incentive period.

SECTION 2.1.(c)  The Department of Health and Human Services, in collaboration with the North Carolina Medical Board, shall promote this continuing medical education incentive and other available training opportunities approved by the North Carolina Medical Board to improve healthcare provider competency in menopause‑related care.

part IIi. medicaid and health insurance coverage of menopause‑related care

MEDICAID COVERAGE OF MENOPAUSE‑RELATED CARE

SECTION 3.1.  The Department of Health and Human Services, Division of Health Benefits (DHB), shall take all necessary actions, including seeking approval from the Centers for Medicare and Medicaid Services (CMS), to implement Medicaid coverage for menopause‑related care. This coverage shall include (i) diagnosis and treatment of perimenopause, menopause, and postmenopause, (ii) hormone replacement therapy (HRT), where medically appropriate, (iii) non‑hormonal treatments and therapies, (iv) behavioral health services related to menopause symptoms, and (v) preventive screenings and counseling. DHB shall ensure that this coverage is provided without undue utilization management barriers and that clinical coverage policies reflect current clinical standards and evidence‑based guidelines.

HEALTH INSURANCE COVERAGE OF MENOPAUSE‑RELATED CARE

SECTION 3.2.(a)  Article 3 of Chapter 58 of the General Statutes is amended by adding a new section to read:

§ 58‑3‑271.  Coverage for perimenopausal and menopausal care.

(a)        The following definitions apply in this section:

(1)        FDA. – The federal Food and Drug Administration.

(2)        Formulation. – Any of the following:

a.         A tablet or capsule.

b.         A transdermal patch.

c.         A topical spray.

d.         A cream, gel, or lotion.

e.         A suppository, cream, or silicone ring.

(3)        Reserved for future codification purposes.

(4)        Menopause. – The permanent cessation of ovulation so that ovaries stop releasing follicles and stop producing estrogen and progesterone. For individuals with an intact uterus, menopause is marked by a 12‑month absence of menstruation.

(5)        Method of administration. – Administering a formulation via an oral, topical, vaginal, rectal, subcutaneous, injectable, or intravenous route of administration.

(6)        Perimenopause. – The transition period from the late reproductive phase to the permanent cessation of ovarian function with absence of menstruation.

(b)        A health benefit plan offered in this State shall provide coverage for perimenopausal and menopausal care and treatment administered by a licensed healthcare provider acting within the scope of the provider's license. This coverage shall include, at a minimum, coverage for all of the following symptoms of perimenopause and menopause:

(1)        Irregular to heavy menstrual period.

(2)        Temporary cognitive changes related to the menopause transition.

(3)        Vaginal or bladder symptoms.

(4)        Decrease in fertility.

(5)        Loss of bone.

(6)        Hot flashes.

(7)        Mood changes.

(8)        Weight gain.

(9)        Increase in low‑density lipoprotein cholesterol levels.

(10)      Sleep disruption, including night sweats.

(c)        Coverage required under subsection (b) of this section shall not be subject to annual deductibles, copayments, or coinsurance.

(d)       A health benefit plan that offers coverage for outpatient prescription drugs shall include coverage for the evaluation and treatment options for symptoms of perimenopause and menopause, as is deemed necessary by the treating healthcare provider. Coverage under this section includes coverage for the treating healthcare provider to adjust the dose of a prescription drug consistent with clinical care recommendations.

(e)        Coverage required under subsection (d) of this section shall be provided without the use of any utilization management for any treatments that are approved by the FDA, including, at a minimum, all of the following:

(1)        At least one outpatient prescription drug in each formulation of, and the associated method of administration for, FDA‑regulated systemic hormone therapy.

(2)        At least one outpatient prescription drug in each formulation of, and the associated method of administration for, non‑hormonal medicals for each menopause symptom.

(3)        At least one outpatient prescription drug in each formulation of, and the associated method of administration for, treatment of genitourinary syndrome of menopause.

(4)        At least one outpatient prescription drug from each class of medications approved to prevent and treat osteoporosis.

(f)        Coverage under this section shall be provided without discrimination on the basis of gender expression or identity.

(g)        An insurer offering a health benefit with coverage under this section shall annually provide current clinical care recommendations for hormone therapy from the Menopause Society or any other nationally recognized professional association to all primary care providers that (i) are contracted as providers participating in an insurer's provider network and (ii) treat covered persons with perimenopause and menopause.

(h)        Nothing in this section shall be construed to limit the coverage for medically necessary outpatient prescription drugs.

SECTION 3.2.(b)  This section is effective October 1, 2027, and applies to insurance contracts issued, renewed, or amended on or after that date.

SECTION 3.3.(a)  G.S. 135‑48.51 reads as rewritten:

§ 135‑48.51.  Coverage and operational mandates related to Chapter 58 of the General Statutes.

The following provisions of Chapter 58 of the General Statutes apply to the State Health Plan:

…

(9a)      G.S. 58‑3‑271, Coverage for perimenopausal and menopausal care.

….

SECTION 3.3.(b)  This section is effective October 1, 2027, and applies as of the start of the next plan year following that date.

part iv. PROTECTIONS AGAINST EMPLOYMENT DISCRIMINATION ON ACCOUNT OF MENOPAUSE

SECTION 4.1.  Chapter 95 of the General Statutes is amended by adding a new Article to read:

Article 24.

Menopause Nondiscrimination Act.

§ 95‑280.  Definitions; findings; scope.

(a)        The General Assembly finds that:

(1)        A significant portion of the North Carolina workforce experiences menopause during peak career years, and the protections afforded by this Article are necessary to support workforce retention and economic stability.

(2)        No worker in this State should experience discrimination, harassment, or bullying based on biological conditions that are largely outside of their control.

(b)        The following definitions apply in this Article:

(1)        Qualified employee or prospective employee. – A person who, with or without reasonable accommodations, can perform the essential functions of the employment position that the individual holds or desires. For the purposes of this Article, due consideration shall be given to the employer's judgment as to what functions of a job are essential, and if an employer has prepared a written description before advertising or interviewing applicants for the job, this description shall be considered evidence of the essential functions of the job. The fact that an individual has applied for, received, or continues to receive private insurance or government assistance based upon the individual's disability shall not be determinative as to whether the individual is qualified as defined herein nor shall it constitute an estoppel or otherwise serve as a basis to deny the individual the protections of this Article.

a.         A qualified individual with a disability does not include any employee or applicant who is currently engaging in the illegal use of drugs, when the employer acts on the basis of such use.

b.         The term illegal use of drugs means the use of drugs, the possession or distribution of which is unlawful under the Controlled Substances Act, 21 U.S.C. § 812. The term does not include the use of a drug taken under supervision by a licensed healthcare professional or other uses authorized by the Controlled Substances Act or other provisions of federal law.

c.         The term drug means a controlled substance, as defined in schedules I through V of section 202 of the Controlled Substances Act.

(2)        Reasonably accommodate. – Providing reasonable accommodations, including, but not limited to, more frequent or longer breaks, time off to recover from childbirth, acquisition or modification of equipment, seating, temporary transfer to a less strenuous or hazardous position, job restructuring, light duty, break time and private non‑bathroom space for expressing breast milk, assistance with manual labor, or modified work schedules.

(3)        Related conditions. – Includes, but is not limited to, lactation or the need to express breast milk for a nursing child or the need to manage the effects of vasomotor symptoms.

(4)        Undue hardship. – An action requiring significant difficulty or expense to the employer. In making a determination of undue hardship, the factors that may be considered include, but shall not be limited to, the following:

a.         The nature and cost of the accommodation;

b.         The overall financial resources of the employer, the overall size of the business of the employer with respect to the number of employees, and the number, type, and location of its facilities; and

c.         The effect on expenses and resources or the impact otherwise of such accommodation upon the operation of the employer. Provided that the fact that the employer provides, or would be required to provide, a similar accommodation to other classes of employees who need it, such as those who are injured on the job or those with disabilities, shall create a rebuttable presumption that the accommodation does not impose an undue hardship on the employer.

(c)        This Article applies to employers having four or more employees.

§ 95‑281.  Menopause discrimination unlawful; rights; obligations.

(a)        It is an unlawful employment practice for an employer to do any of the following:

(1)        Refuse to reasonably accommodate an employee's or prospective employee's condition related to pregnancy, childbirth, menopause, or a related medical condition, including, but not limited to, the need to express breast milk for a nursing child, if she so requests, unless the employer can demonstrate that the accommodation would pose an undue hardship on the employer's program, enterprise, or business.

(2)        Require an employee to take leave if another reasonable accommodation can be provided to an employee's condition related to pregnancy, childbirth, menopause, or a related medical condition.

(3)        Deny employment opportunities to an employee or prospective employee, if such denial is based on the refusal of the employer to reasonably accommodate an employee's or prospective employee's condition related to pregnancy, childbirth, menopause, or a related medical condition.

(4)        Fail to provide written notice, including notice conspicuously posted at an employer's place of business in an area accessible to employees, of the right to be free from discrimination in relation to pregnancy, childbirth, menopause, and related conditions, including the right to reasonable accommodations for conditions related to pregnancy, childbirth, menopause, or related conditions pursuant to this section to:

a.         New employees at the commencement of employment.

b.         Existing employees within 120 days after the effective date of December 1, 2026.

c.         Any employee who notifies the employer of her pregnancy or menopause within 10 days of such notification.

(b)        It is unlawful for any person, whether or not an employer, employment agency, labor organization, or employee, to aid, abet, incite, compel, or coerce the doing of any act declared by this section to be an unlawful employment practice or to obstruct or prevent any person from complying with the provisions of this section or any order issued pursuant to this section or to attempt directly or indirectly to commit any act declared by this section to be an unlawful employment practice.

(c)        The employer shall have the burden of proving undue hardship. The fact that the employer provides, or would be required to provide, a similar accommodation to other classes of employees who need it, such as those who are injured on the job or those with disabilities, shall create a rebuttable presumption that the accommodation does not impose an undue hardship on the employer.

(d)       No employer shall be required by this section to create additional employment that the employer would not otherwise have created, unless the employer does so, or would do so, for other classes of employees who need accommodation, such as those who are injured on the job or those with disabilities.

(e)        No employer shall be required to discharge any employee, transfer any employee with more seniority, or promote any employee who is not qualified to perform the job, unless the employer does so, or would do so, to accommodate other classes of employees who need it, such as those who are injured on the job or those with disabilities.

§ 95‑282.  Menopause recognized for employment protections; reasonable accommodations.

(a)        Employers shall provide reasonable accommodations for employees experiencing menopause‑related symptoms, similar to protections afforded for pregnancy‑related conditions.

(b)        Employers shall not retaliate against employees who request accommodations related to menopause.

(c)        Reasonable accommodations for physically demanding work may include, but are not limited to, the following:

(1)        Extra or frequent breaks throughout the day.

(2)        Access to cold water or cooling devices such as fans, towels, and misters.

(3)        Consistent access to restrooms.

(4)        Flexible uniforms or adapted dress codes.

(5)        Comfortable workspaces, such as adjustable temperature and dedicated rest areas.

(6)        Shift in job duties to reduce physical labor.

(7)        Designated areas to freshen up, change clothes, or access sanitary products.

(d)       Reasonable accommodations for intellectually demanding work may include, but are not limited to, the following:

(1)        Flexible work hours or alternative work schedules.

(2)        Flexible deadlines or deadline extensions, as appropriate.

(3)        Use of supportive services and devices, such as adjustable desk furniture, notetaking support, and adaptive tools.

(4)        Access to quiet workspaces or white noise sound machines.

(5)        Broad spectrum or natural lighting.

(6)        Flexible meeting schedules.

(7)        Access to task management tools.

(e)        Reasonable accommodations for emotionally demanding work may include, but are not limited to, the following:

(1)        Time off for medical appointments.

(2)        Telework options.

(3)        Employee resource groups.

(4)        Individual coaching or therapy sessions.

(5)        Employee assistance programs (EAPs).

(f)        Employers are encouraged to implement supportive workplace policies, including:

(1)        Employee assistance programs (EAPs).

(2)        Employee resource groups (ERGs).

(3)        Education and awareness initiatives.

(g)        Menopause and menopause‑related conditions shall be recognized under State employment discrimination and nonretaliation protections granted by this Chapter or by any other provision of State law.

§ 95‑283.  Construction of Article.

Nothing in this Article shall be construed to:

(1)        Require an individual with a need related to pregnancy, childbirth, menopause, or a related medical condition to accept an accommodation which the individual chooses not to accept.

(2)        Affect any other provision of law relating to sex discrimination, pregnancy, or menopause or to preempt, limit, diminish, or otherwise affect any other law that provides greater protection or specific benefits with respect to pregnancy, childbirth, menopause, or medical conditions related to childbirth or menopause.

SECTION 4.2.  Effective July 1, 2026, there is appropriated from the General Fund to the Department of Labor the sum of five hundred thousand dollars ($500,000) for the 2026‑2027 fiscal year for implementation of this act.

SECTION 4.3.  Except as otherwise provided, this Part becomes effective December 1, 2026, and applies to hiring and employment decisions made, and actions taken, on or after that date.

part v. effective date

SECTION 5.1.  Except as otherwise provided, this act is effective when it becomes law.