← Back to list
26-1184 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 will no longer reimburse gender-affirming surgical interventions, puberty blockers, and hormone therapy for members under age 18 (CHIP under 19) due to federal funding restrictions. Members receiving hormone therapy Previously due October 13, 2026 (date passed; verify current applicability), may continue reimbursement through April 12, 2027. Billing teams must update authorization workflows, issue Notices of Action to affected members, and continue billing for non-affected medically necessary services.
Get alerts when payers change rules like this one
We check Health Net and other payers every day and email you when a change matches your specialty and state.
Get Health Net alertsPolicy Monitoring is free. No card required.
What to do
Action · 11 steps
01EFFECTIVE DATE (ALREADY PASSED): October 13, 2026 — This policy is now in effect.
02IMMEDIATE ACTIONS FOR BILLING TEAM.
03Verify implementation of the reimbursement restriction for surgical interventions (mastectomy, breast augmentation), puberty blockers, and hormone therapy for Medi-Cal members under 18 and CHIP members under 19 in affected counties.
04Continue processing claims for gender-affirming care provided on or Previously due October 12, 2026 (date passed; verify current applicability), under existing requirements.
05For members receiving hormone therapy Previously due October 13, 2026 (date passed; verify current applicability), ensure reimbursement continues through the transition period ending April 12, 2027; hormone therapy billed under medical benefit (not pharmacy) is eligible for extended coverage.
06For previously authorized surgical interventions scheduled on or after October 13, 2026, contact California HCAI if prior authorization was approved before the effective date.
07Participating Physician Groups (PPGs) delegated for authorizations must issue individualized Notices of Action (NOA) for any affected services being terminated, suspended, or reduced; NOA must be sent at least 10 days before the effective date of termination/reduction, identifying the adverse benefit determination and explaining the federal reimbursement restriction.
08Retain all previously approved authorizations; do not cancel affected services or redirect members pending additional state guidance.
09Continue billing and delivering all other medically necessary services, including office visits, laboratory tests, speech therapy, psychotherapy, treatment of complications, and services to treat medical conditions other than gender dysphoria.
10Monitor California HCAI and DHCS for additional guidance regarding the state-funded reimbursement pathway under development.
11FUTURE DEADLINE: By April 12, 2027, transition period for hormone therapy reimbursement expires; confirm current applicability of extended coverage for individual members at that time.
Original notice
26-1184 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
Related changes
See all Health Net changes →26-1186 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026HighEffective Oct 13, 2026 · Prior Authorization26-1185 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026HighEffective Oct 13, 2026 · Prior AuthorizationBrowse every Health Net change in the policy list