LEGISLATIVE FISCAL ESTIMATE

SENATE COMMITTEE SUBSTITUTE FOR

SENATE, Nos. 4294 and 693

STATE OF NEW JERSEY

221st LEGISLATURE

 

DATED: JANUARY 8, 2026

 

 

SUMMARY

 

Synopsis:

Requires unrestricted Medicaid coverage for ovulation enhancing drugs and medical services related to administering such drugs for certain beneficiaries experiencing infertility.

Type of Impact:

Annual increases in State expenditures and revenues.

Agencies Affected:

Department of Human Services.

 

 

Office of Legislative Services Estimate

Fiscal Impact

Annual

 

State Expenditure Increase

Indeterminate

 

State Revenue Increase

Indeterminate

 

 

·         The Office of Legislative Services (OLS) concludes that annual NJ FamilyCare costs will increase by an indeterminate amount to cover up to three rounds of medically necessary ovulation enhancing medications and certain medical services related to prescribing and monitoring the use of such drugs for NJ FamilyCare enrollees, ages 21 through 44 years, who are experiencing infertility.  Given that approximately 95 percent of NJ FamilyCare beneficiaries are enrolled in one of the five State-contracted NJ FamilyCare managed care plans, and the State’s contract with the NJ FamilyCare managed care organizations specifically precludes coverage for services provided primarily for the diagnosis and treatment of infertility, the OLS cannot determine with certainty the amount by which NJ FamilyCare costs would increase under the bill.

 

·         To the extent that State Medicaid expenditures increase under the bill, State revenues will increase in the form of federal Medicaid reimbursements.

 

 

BILL DESCRIPTION

 

      The bill requires NJ FamilyCare coverage for medically-necessary ovulation enhancing drugs and the medical services related to prescribing and monitoring the use of such drugs for enrollees, ages 21 through 44 years, who are experiencing infertility, provided that there is federal financial participation available under the federal Medicaid program.  Coverage of ovulation enhancing drugs and related medical services is limited to three cycles of treatment per lifetime of the beneficiary. 

      Medical services covered under the bill are limited to office visits, hysterosalpingograms, pelvic ultrasounds, and blood testing.

 

 

FISCAL ANALYSIS

 

EXECUTIVE BRANCH

 

      None received.

 

OFFICE OF LEGISLATIVE SERVICES

 

      The OLS concludes that annual NJ FamilyCare costs will increase by an indeterminate amount to provide up to three cycles of medically-necessary ovulation enhancing medications and certain medical services related to prescribing and monitoring the use of such drugs for enrollees, ages 21 through 44 years, who are experiencing infertility.  Given that approximately 95 percent of NJ FamilyCare beneficiaries are enrolled in one of the five State-contracted NJ FamilyCare managed care plans, and the State’s contract with the Medicaid managed care organizations specifically precludes coverage for services provided primarily for the diagnosis and treatment of infertility, the OLS lacks the informational basis to determine how demand for fertility preservation services may change as a result of the bill and how much the associated State costs would increase.  To the extent that State Medicaid expenditures increase under the bill, State revenues will increase, in the form of federal Medicaid reimbursements.

      For context, the 2024 KFF Women’s Health Survey found that 10 percent of respondents with incomes below 200 percent of the federal poverty level required fertility services in order to become pregnant; of these, 28 percent were prescribed ovulation enhancing medications.  Of the 722,657 NJ FamilyCare expansion adults over the age of 20 years who are enrolled as of May 2025, approximately 411,915 (57 percent) are women.  The NJ FamilyCare enrollment reports, however, do not further disaggregate enrollment data by age.  According to the KFF Women’s Health Survey, just four percent of women ages 18 to 25 years reported needing fertility services in order to become pregnant.

      This bill mirrors the infertility benefit provided under the New York Medicaid program.  In FY 2018, the first full year in which the New York Medicaid program covered ovulation enhancing medications and related medical services for enrollees experiencing infertility, the state estimated that federal Medicaid costs for the new benefit would total $45,000, suggesting that total state and federal costs would approximate $90,000 that year.  However, the New York benefit covers four specific ovulation enhancing medications; by contrast, A5383 does not specify which ovulation enhancing medications would be covered under the bill.  While list prices for the generic versions of certain oral ovulation enhancing medications can be under $100.00 per month, list prices for certain hormonal injections to stimulate ovulation can reach thousands of dollars per cycle.

Section:

Human Services

Analyst:

Anne Cappabianca

Senior Fiscal Analyst

Approved:

Thomas Koenig

Legislative Budget and Finance Officer

 

 

This legislative fiscal estimate has been produced by the Office of Legislative Services due to the failure of the Executive Branch to respond to our request for a fiscal note.

 

This fiscal estimate has been prepared pursuant to P.L.1980, c.67 (C.52:13B-6 et seq.).