On December 18, 2025, the Centers for Medicare and medicaid Services (CMS) issued two proposed rules that would further limit youth access to gender affirming care. One rule would change the hospital conditions of Participation (CoPs) which would prohibit most Medicare and Medicaid enrolled hospitals from providing specified gender affirming medical care for youth (the proposed CoPs rule). The second proposed rule would prohibit federal Medicaid or CHIP funds from covering this care for youth (the proposed Medicaid rule). Despite gender affirming care being considered a best practice model of care and consisting of interventions recommended by major medical associations,if finalized and implemented,the proposed rules would have a sweeping impact,albeit for a small number of young people,significantly limiting their access to these services.

The rules broadly align with a range of other administrative actions that take a multipronged approach to restrict this care. In particular, the proposed rules follow a January 2025 Executive Order that set a pathway for limiting youth access to gender affirming care and directed the Secretary of Health and Human Services (HHS) to “take all appropriate actions to end” gender affirming care for youth, including in Medicaid, and which specifically identified the CoPs as a possible vehicle for this. Additionally, on april 11, 2025, CMS sent a State Medicaid Director’s letter with the stated purpose of “reminding states of their duty to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients” and appearing to encourage states to take steps to limit gender affirming care for youth within their state Medicaid programs. Then, in may 2025, HHS sent a second letter to an unspecified group of providers, state medical boards, and health risk managers urging them to update treatment protocol to move away from provision of gender affirming medical care.

the proposed rules do not take effect instantly. Both have a 60-day comment period following their publication in the federal register. Then, following the comment period, CMS is tasked with considering the comments and could ultimately choose to finalize the proposed rule-either in amended form or as currently written-or elect not to do so. If finalized, both rules will likely face legal challenges, which could further slow implementation.

The Proposed Conditions of Participation (CoPs) Rule

If finalized, the proposed hospital CoPs rule would limit gender affirming care for youth, irrespective of payer. The CoPs rule proposes to prohibit certain hospitals (i.e. those covered by section 42 CFR part 482

proposed Rules Threaten Access to Gender Affirming Care for Youth

The landscape of gender affirming care for youth is facing new challenges with proposed rules from the Centers for Medicare & medicaid Services (CMS). These rules, impacting both hospital services and Medicaid/CHIP funding, could significantly limit access to care for transgender and gender diverse youth across the country.

Impact on Hospitals: Conditions of Participation (CoPs)

Currently, the extent of gender affirming care offered in hospitals is unclear, with many systems recently pausing services due to growing concerns about legal and regulatory pressures. examples include Children’s Hospital of Los Angeles, citing a “complex and uncertain regulatory habitat,” and Children’s National, referencing “escalating legal and regulatory risks.”

If finalized, the proposed CoPs rule would largely prohibit hospitals from providing gender affirming care services for youth. While hospitals could opt out of Medicare and Medicaid to continue offering these services, the significant financial implications – nearly half of all hospital care spending nationally comes from these programs – make this highly unlikely.

Despite the broad request of the rule, hospitals currently provide a relatively small number of gender affirming care services to youth, with gender affirming surgeries being particularly rare.The proposed rule estimates it would impact 8,570 young people, representing approximately 1.2% of the estimated 724,000 trans youth (ages 13-17) in the U.S. who receive such care in hospitals. The CMS analysis aligns with past research, finding that most care is pharmacologic, with only 85 surgeries identified in impacted facilities nationwide over one year – less than 0.0003% of the U.S. youth population aged 12-18.

While care could still be sought outside of hospitals, access is already challenging. Many services, like puberty blockers and hormone therapies, can be provided in outpatient settings. However, patients may face increased travel distances and costs. Finding specialized pediatric gender clinics offering extensive, integrated care may also become more difficult, as these clinics are frequently enough hospital-based. The proposal itself acknowledges potential difficulties in finding in-network providers and increased commute times, estimating that 4,285 youth may discontinue care as a result.

The Proposed Medicaid Rule

The proposed Medicaid rule would further restrict access by prohibiting the use of federal Medicaid and CHIP funds to cover specified gender affirming care services – the same pharmaceutical and surgical services targeted by the CoPs rule. Unlike the cops proposal, which focuses on the location of care (hospitals), the Medicaid proposal targets care based on the payer (Medicaid or CHIP), regardless of where it’s received.

Proposed Rules Could Limit Gender-Affirming Care for Youth

Recent proposed rules regarding Medicaid and the Children’s Health Insurance Program (CHIP) could significantly restrict access to gender-affirming medical services for young people. While current data indicates the uptake of these services is relatively low, the proposed changes could further limit options for those seeking care. The rules, if finalized, threaten to prevent individuals from receiving covered care.

Young people with Medicaid and CHIP coverage might theoretically seek care outside of hospital settings without utilizing their insurance.However, the financial burden of doing so would likely be ample. Families relying on Medicaid and CHIP generally have low to moderate incomes, making it difficult to afford uncovered medical expenses.

Looking Ahead

As previously mentioned,these proposed rules are not yet in effect. If finalized after a 60-day comment period, they will likely further restrict access to gender-affirming care for youth. Individuals with greater financial resources and support systems will be better positioned to navigate access challenges – such as traveling to providers or utilizing commercial insurance. Conversely, those with limited resources and Medicaid/CHIP coverage, designed for low-income families, could face the most significant obstacles. It’s vital to note these rules do not impact other forms of care for transgender young people.

Losing access to gender-affirming care can have serious consequences for transgender youth.

Key Takeaways

• Proposed rules could limit Medicaid/CHIP coverage for gender-affirming care.
• financial barriers will likely disproportionately affect low-income families.
• Access to care will likely vary based on financial resources and insurance coverage.
• The rules do not affect other types of healthcare for transgender youth.

FAQ

What is gender-affirming care?

Gender-affirming care encompasses a range of medical, psychological, and social services designed to support individuals in aligning their gender expression with their gender identity. This can include social transition, hormone therapy, and surgery.

Who is affected by these proposed rules?

primarily, young people covered by Medicaid and CHIP who are seeking gender-affirming care will be affected. Families with low to moderate incomes are particularly vulnerable.

What happens during the 60-day comment period?

The 60-day comment period allows the public to submit feedback on the proposed rules. This feedback is considered before a final decision is made.

2025/12/23 00:54:10