Federal Reimbursement Limitation on Gender-Affirming Care Services for Youth
| Date: | October 28, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers and Practitioners |
| Type: | Regulatory |
| Subject: | Federal Reimbursement Limitation on Gender-Affirming Care Services for Youth |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) issued All Plan Letter (APL) 26- 018 Federal Reimbursement Limitation on Gender-Affirming Care Servcies for Youth found at https://www.dhcs.ca.gov/wp-content/uploads/2026/09/APL-26- 018-GAC.pdf. Effective for dates of service (DOS) on or after October 13, 2026, Medi-Cal and Managed Care Plans (MCPs) will no longer pay for specific gender-affirming care services (referred to in the Final Rule as “sex-rejecting procedures”) when it is used to treat gender dysphoria for Medi-Cal members under age 18 and for Children’s Health Insurance Program (CHIP) members under age 19. This Final Rule does not apply to Medi-Cal members ages 18 or older.
Services affected:
- Surgical interventions, such as mastectomy or breast augmentation
- Puberty blockers, such as gonadotropin-releasing hormone agonists and their injection or implantation, and associated professional services
- Hormone therapy, such as estrogen or testosterone, injection or implantation, and associated professional services
This does not mean members cannot get care. California supports access to medically necessary care. The state will use state funds to pay for medically necessary gender-affirming care for Medi-Cal and CHIP members when it is clinically appropriate and recommended by a qualified provider.
The California Department of Health Care Access and Information (HCAI) will help pay for the affected services. This program is separate from Medi-Cal, which is overseen by the DHCS. More details will be posted on the HCAI and DHCS websites when they are available.
MCPs will continue to cover the services outlined above for Medi-Cal members under the age of 18 and for CHIP members under the age of 19 when medically necessary to treat medical conditions other than gender dysphoria. MCPs remain responsible for covering all other medically necessary services for Medi-Cal members under the age of 18 and for CHIP Members under the age of 19 that fall outside of the categories specified above, including office visits, laboratory tests, speech therapy and psychotherapy as these services do not fall within the scope of the Final Rule, regardless of their purpose or whether they are associated with the treatment of gender dysphoria. MCPs must also cover the services listed above when medically necessary to treat complications, including any infection, injury, disease, or disorder that has been caused by or exacerbated by the provision of the non-reimbursable services listed.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
