← Back to list
26-1186 Reimbursement Changes for Gender-Affirming Care, Effective October 13, 2026
Effective date
Oct 13, 2026
Identified
Oct 28, 2026
Summary
Effective October 13, 2026, Medi-Cal and CHIP will no longer reimburse gender-affirming surgical interventions, puberty blockers, and hormone therapy for minors (under 18 for Medi-Cal, under 19 for CHIP), with a limited transition period through April 12, 2027 for members already receiving hormone therapy. Billing teams must implement prior authorization denials, issue required Notices of Action, 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 · 3 steps
01At least 10 days Previously due October 13, 2026 (date passed; verify current applicability) (i.e., by approximately October 3, 2026): Participating Physician Groups delegated for prior authorizations must issue individualized Notices of Action (NOA) to members whose previously authorized gender-affirming care services (surgical interventions, puberty blockers, hormone therapy) will be terminated, suspended, or reduced on or after October 13, 2026.
02The NOA must identify the adverse benefit determination, explain the federal reimbursement restriction, and include information about appeal rights, State Hearing rights, and continuation of benefits where applicable.
03Billing team must: (1) implement workflow changes to deny or redirect claims for surgical interventions, puberty blockers, and new hormone therapy starts on or after October 13, 2026 for affected minors; (2) retain and honor previously approved prior authorizations through their stated authorization period; (3) process claims for medically necessary gender-affirming care provided on or Previously due October 12, 2026 (date passed; verify current applicability) under existing requirements; (4) continue billing and delivering non-affected services including office visits, laboratory tests, speech therapy, psychotherapy, and treatment of complications; (5) for hormone therapy cases: allow reimbursement through April 12, 2027 ONLY for members receiving hormone therapy Previously due October 13, 2026 (date passed; verify current applicability) when billed under medical benefit; (6) contact California HCAI regarding any surgical interventions scheduled on or after October 13, 2026 that had prior authorization approved before that date; (7) monitor future state guidance regarding the state-funded reimbursement pathway.
Original notice
26-1186 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 →26-1184 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