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Health NetMedicaid · Coverage · Prior Authorization · CA · Endocrinology, Psychiatry, Speech Therapy +1 moreHigh impact

26-1185 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026

Effective date
Oct 13, 2026
Identified
Oct 21, 2026

Summary

Effective October 13, 2026, Medi-Cal and CHIP plans in California (Fresno, Kings, Madera counties) will no longer reimburse gender-affirming surgical interventions, puberty blockers, and hormone therapy for members under age 18/19 due to federal funding restrictions. Members already receiving hormone therapy Previously due October 13, 2026 (date passed; verify current applicability), may continue reimbursement through April 12, 2027. Billing teams must issue Notices of Action for affected authorizations, retain previously approved authorizations for services provided before the cutoff, and continue billing for non-gender-affirming medically necessary services.

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What to do

Action · 9 steps
01IMMEDIATE (Effective October 13, 2026 – policy is now in effect): Billing and authorization teams should.
02Identify all active prior authorizations for gender-affirming surgical interventions, puberty blockers, and hormone therapy for Medi-Cal members under age 18 and CHIP members under age 19 in Fresno, Kings, and Madera counties.
03For services provided on or Previously due October 12, 2026 (date passed; verify current applicability), continue processing claims under existing requirements.
04For previously authorized services extending beyond October 13, 2026 that will be terminated, suspended, or reduced, ensure participating physician groups issue individualized Notices of Action at least 10 days before the effective date of termination or reduction, identifying the adverse benefit determination and explaining the federal rule prohibition.
05For surgical interventions scheduled on or after October 13, 2026 with prior authorizations approved Previously due October 13, 2026 (date passed; verify current applicability), contact California Department of Health Care Access and Information (HCAI) for guidance.
06Retain previously approved authorizations and do not cancel affected services or redirect members.
07For members receiving hormone therapy Previously due October 13, 2026 (date passed; verify current applicability), continue reimbursing those medications through April 12, 2027 (transition period does not apply to new initiations on or after October 13, 2026, puberty blockers, or surgical interventions).
08Continue billing for all medically necessary non-gender-affirming services, office visits, laboratory tests, speech therapy, psychotherapy, and treatment of complications.
09Monitor California for state-funded reimbursement pathway guidance.
If missed: Failure to issue required Notices of Action may result in non-compliance with federal and state notice requirements.

Original notice

26-1185 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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