Insurance is often a barrier to menopause symptom treatment. California lawmakers want to change that

Some people experiencing menopause symptoms miss out on treatment because their insurance won't cover it. That could harm patients and frustrates providers — and California lawmakers are taking notice. 

“Absolutely insurance impacts people's ability to access care,” said Dr. Karen Adams, director of the Stanford University Program in Menopause and Healthy Aging.

She said doctors can appeal denials, and often do.

“It is really a requirement that the provider go that extra mile to advocate for their patient with the insurance companies,” Adams said, adding that the process wastes valuable time for providers, their staff and patients whose health and well-being depend on treatment. 

Even when doctors appeal, there’s no guarantee they will win, she said. 

Adams was one of the authors of a study, which was published last year in the journal Menopause. It concluded that over 60% of people experiencing moderate to severe menopause symptoms were not receiving any treatment. 

“We found that it's pretty abysmal all the way across the board,” she said. “But it's even worse if people are on public insurance or uninsured.”

Treatment can be prohibitively expensive for many, even when recommended by a doctor. That’s especially true for people of color, without legal status or who live in rural areas. 

Adams said co-pays for menopause treatment can cost over a thousand dollars a year. That forces many people to opt out — and with it, lose out on preventative care entirely.

“It's life-threatening. It is literally life-threatening,” she said. 

Assembly Bill 432, which is moving through the California legislature, would require insurance plans to cover certain kinds of menopause symptom treatments, including hormone replacement therapy and osteoporosis treatment and prevention. 

“We just decided to say, ‘You know what? We're going to say it needs to be covered because we believe it's medically necessary,’” said Bay Area Democratic Assembly member Rebecca Bauer-Kahan, who wrote the bill. 

Two states have already passed laws that require plans to cover some menopause symptom treatments. In Illinois, plans have been required since 2023 to cover symptom treatment when a patient experiences early menopausal symptoms after having a hysterectomy. Louisiana passed a law in 2023 mandating plans cover treatment for menopause and perimenopause.

Last year, California’s Democratic Governor Gavin Newsom vetoed a similar bill, also authored by Bauer-Kahan, calling it “too far-reaching” in what it required health plans to cover. 

Newsom’s office declined to comment on the new bill for this story. 

The California Association of Health Plans, which represents insurers, has spoken out against the new bill and others like it. 

Mary Ellen Grant, a spokesperson for the organization, turned down an interview, but said in a statement that the organization doesn’t support the bill because it rolls back prior authorization, adding that it’s a critical tool “used by health plans that ensures care aligns with the latest medical guidelines while protecting patients from unnecessary procedures, excessive costs, and harmful treatments.”

Prior authorization is a process by which insurance companies require providers to submit for approval on individual treatments or procedures. Companies say it keeps costs down, but providers say it’s a barrier to care. 

Garen Corbett is the director of the California Health Benefits Review Program at UC Berkeley, which analyzes legislation that relates to health plan benefits. He said each insurance company has its own way of handling how it covers treatment approval — which complicates regulating them.

“A lot is happening to sort of move towards better guidelines and consistency,” he said. 

But several bills moving through the legislature — including the menopause bill — would do just that. 

These measures include a proposal to ban insurance companies from using prior authorization for HIV and AIDS treatment, insulin and even air purifiers for people near wildfire smoke. 

Corbett said that policy trend has grown as health care costs continue to rise.  

“It's part and parcel of this long-term struggle of, how do you provide broad access and maintain affordability?” he said, adding that legislators are limited in the tools they have to do that. 

He said they are taking a piecemeal approach, mostly because there’s no single solution for every situation.

“It is really hard to get consensus and buy-in, particularly if there's a big issue that's really complicated affecting a lot of players,” he said. 

Le Ondra Clark Harvey, chief executive officer of the advocacy group California Behavioral Health Association, believes insurance plans have gone too far in their use of prior authorization. She said these bills would provide needed regulation. 

“The gaping hole is pretty obvious here,” she said. “That's why so many folks are all over this.”

She pointed out that Californians can appeal denials through the Department of Managed Health Care, but said that’s not enough. 

“Most consumers, despite the legal postings that are in doctors' offices, etc., really don't make it to the level where they are challenging” denials, she said. 

If the menopause bill or any other bill trying to address prior authorization becomes law, Clark Harvey said  it could provide a blueprint for scaling back unnecessary denials.