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New Federal Reimbursement Limitations on Gender Affirming Care for Youth, Effective October 13, 2026
Act
by Oct 13, 2026
Effective date
Oct 13, 2026
Identified
Sep 26, 2026
Summary
Effective October 13, 2026, California will prohibit Medi-Cal and CHIP federal reimbursement for gender-affirming surgical interventions and medications (puberty blockers, hormone therapy) for members under 18/19 years old. These services will shift to state-only HCAI grant funding instead of traditional Medi-Cal claims. Existing hormone therapy patients have a six-month transition period (through April 12, 2027) to continue Medi-Cal reimbursement. Billing teams must implement new claim routing workflows and monitor HCAI guidance.
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What to do
by Oct 13, 2026 · 7 steps
01Billing team must update claim submission workflows to STOP submitting Medi-Cal/CHIP claims for gender-affirming surgical interventions and medications (puberty blockers, hormone therapy) for patients under 18/19 with DOS on or after October 13, 2026—these will route to HCAI grant program instead.
02Identify all patients currently on hormone therapy as of October 13, 2026, and flag them for the six-month transition period (through April 12, 2027), during which Medi-Cal will continue reimbursing these medications only.
03Continue submitting Medi-Cal claims for gender-affirming care services that are NOT surgical interventions or medications (e.g., office visits, lab tests, psychotherapy, speech therapy).
04Continue submitting Medi-Cal claims for any medications/surgeries provided for NON-gender-affirming purposes (e.g., hormone therapy for other medical conditions) and for complication management.
05Providers with pre-October 13 surgical authorizations must contact HCAI at genderaffirmingcare@hcai.ca.gov to ensure continued funding for scheduled procedures.
06Monitor HCAI's Gender Affirming Care and Reproductive Health Programs webpage and DHCS/HCAI subscription services for pending guidance on medication reimbursement processes and retroactive payment procedures.
07DO NOT cancel services or redirect patients—HCAI will provide retroactive reimbursement once the grant pathway is established.
If missed: Failure to reroute claims appropriately will result in claim denials under Medi-Cal and delayed reimbursement until HCAI processes are finalized.
Original notice
New Federal Reimbursement Limitations on Gender Affirming Care for Youth, Effective October 13, 2026
mcweb.apps.prd.cammis.medi-cal.ca.gov · Always check the source before changing claims.