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26-1186 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026

Date: 10/27/26

Continue coordinating care for affected members

Effective October 13, 2026, Medi-Cal and Medi-Cal managed care plans will no longer reimburse certain gender-affirming care services provided to Medi-Cal members under age 18 and Children's Health Insurance Program (CHIP) members under age 19. This change is required by a federal rule that prohibits states from claiming federal Medicaid and CHIP matching funds for specified services.

Affected services

The reimbursement restriction applies when the following services are provided as gender-affirming care:

  • Surgical interventions, including mastectomy and breast augmentation.
  • Puberty blockers and associated professional services.
  • Hormone therapy and associated professional services.

Hormone therapy transition period

Affected members receiving gender-affirming hormone therapy before October 13, 2026, may continue to have these medications reimbursed through April 12, 2027. This transition period:

  • Applies only to members receiving hormone therapy before
    October 13, 2026.
  • Does not apply to members who begin hormone therapy on or after October 13, 2026.
  • Does not apply to puberty blockers or surgical interventions.
  • Applies only when the medication is billed under the medical benefit as a medical claim.

Services that remain covered

For affected members, physicians, practitioners and other providers should continue delivering and billing for medically necessary services not affected by the federal rule, including:

  • Affected service to treat medical conditions other than gender dysphoria.
  • Office visits.
  • Laboratory tests.
  • Speech therapy.
  • Psychotherapy.
  • Treatment of complications caused or exacerbated by an affected service.
  • All other medically necessary services for Medi-Cal members under age 18 and for CHIP members under age 19 that fall outside of the categories specified above.

Claims for medically necessary gender-affirming care provided on or before October 12, 2026, will continue to be processed under existing requirements.

Physicians, practitioners and other providers should continue delivering and billing for medically necessary gender-affirming care for Medi-Cal members not affected by the federal rule.

What providers need to do

  1. Continue coordinating medically necessary care for affected members.
  2. Do not cancel affected services or redirect members while additional state guidance is pending.
  3. Retain previously approved authorizations.
  4. Contact the California Department of Health Care Access and Information (HCAI) regarding surgical interventions scheduled on or after October 13, 2026, when prior authorization was approved before that date.
  5. Monitor future guidance regarding reimbursement for affected services.

Notice of Action requirements for PPGs

For members whose previously authorized affected services will be terminated, suspended or reduced because of this federal reimbursement change, participating physician groups (PPGs) that are delegated for such authorizations must ensure that an individualized Notice of Action (NOA) is issued in accordance with applicable federal and state requirements.

For prior authorizations that extend beyond October 13, 2026, the required NOA must be provided at least 10 days before the effective date of the termination or reduction, unless an exception applies. The notice must identify the adverse benefit determination and explain that the affected service will no longer be reimbursed by Medi-Cal on or after October 13, 2026, because of the federal rule. The NOA also must include information about the member's appeal rights, State Hearing rights and, when applicable, continuation of benefits.

State-funded reimbursement pathway

California is developing a state-funded program to support continued access to services affected by the federal funding restriction. Additional information will be shared as guidance becomes available.

Need help? Contact us

For additional information, refer to the Federal Register and DHCS All Plan Letter 26-018 (PDF). For all other questions, contact Community Health Plan of Imperial Valley at 833-236-4141.

 

This information applies to Physicians and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial County.



Last Updated: 10/27/2026