Finalized Federal Rule Reshapes Medicaid Coverage for Gender-Affirming Care for Minors
August 21, 2026
CMS Finalizes Rule on Gender-affirming Medical Care
The Centers for Medicare & Medicaid Services (CMS) has finalized a rule barring federal Medicaid and Children’s Health Insurance Program (CHIP) dollars from paying for certain gender-affirming medical care for minors, marking a significant shift in federal health policy with direct implications for physicians who care for transgender youth.
The rule was finalized on August 11 and covers certain pharmaceutical and surgical interventions intended to alter a patient’s physical characteristics to align with a gender identity different from their sex.
What Physicians Should Know
- The policy takes effect on October 13, 2026, and applies to federal Medicaid funding for patients under 18 and federal CHIP funding for patients under 19.
- It does not prohibit states from using their own funds to cover the services, meaning the practical impact will vary depending on how individual states respond.
- For patients already receiving hormone therapy, CMS is allowing federal funding to continue for a tapering period of up to six months after the rule takes effect.
Where Proponents & Opponents Stand on the Rule
The administration argues the policy is necessary to protect children and ensure taxpayer-funded programs support treatments it considers sufficiently supported by evidence. Supporters of the rule have emphasized concerns about the long-term and potentially irreversible effects of some interventions, while opponents have argued that decisions about gender dysphoria treatment should remain between patients, families and their clinicians and warn that restricting coverage could disrupt established care.
State Attorneys Denied Emergency Stay on Court-ordered Receivership of Prison Health Care System The U.S. Supreme Court on Thursday denied Arizona's last-ditch effort to temporarily halt a court-ordered takeover of health care operations and management within state-run prisons. Without an emergency stay of the court's order, Arizona's Department of Corrections, Rehabilitation and Re-entry must turn over the management of its health care operations for roughly 25,000 incarcerated people to Annette Chambers-Smith, former director of the Ohio Department of Rehabilitation and Correction, beginning on October 19. Roots of the Case The dispute began in 2012 when inmates sued the department, alleging the prison system's inadequate medical, mental health, and dental care amounted to cruel and unusual punishment under the Eighth Amendment. The case went through years of litigation and a failed settlement agreement. In 2023, U.S. District Judge Roslyn Silver ruled that the health care system was "grossly inadequate." The court ordered the prison healthcare system to comply with more than 150 "quality indicators," but according to court-appointed monitors, the department failed to comply with 131 of the measures. In light of this finding, Silver mandated that health care in Arizona prisons would be overseen by Annette Chambers-Smith, former director of the Ohio Department of Rehabilitation and Correction, to take over as receiver effective Oct. 19. A Last-Ditch Appeal Attorneys for the Arizona Department of Corrections, Rehabilitation and Reentry asked the U.S. Supreme Court to delay a court-ordered receivership of the state's prison health care system. The request came after both a federal district court and the 9th U.S. Circuit Court of Appeals declined to pause the takeover. In the application, former U.S. Solicitor General Paul Clement, a representative of the department, argued that the state deserves more time to make its case before surrendering control of its operations, including oversight of its employees and health care budget. Arguments on Both Sides Clement argues receivership should have been the last resort and that Silver moved to it too quickly. He asserted that the department made measurable progress, including growing its health care staffing by more than 50%, expanding substance-use treatment access, and adopting a new care model. Corene Kendrick, deputy director of the American Civil Liberties Union National Prison Project, which represents the roughly 25,000 people incarcerated in Arizona prisons, called the department's request a "Hail Mary" and said Silver gave the department years of opportunities to comply before ordering receivership. What Happens Next Health care for thousands of incarcerated people will be managed under Chambers-Smith's oversight, as mandated by Silver, beginning on Oct. 19. The receivership affects all nine of Arizona's state-run prisons but will not impact health care for inmates in private facilities. Information in this article was sourced from the Arizona Mirror and Arizona's Family .
Eligible clinicians and group practices can request a targeted review of their final score before 2027 payment adjustments take effect. Final Scores Are Out, Adjustments Follow in About a Month The Centers for Medicare & Medicaid Services has released Merit-based Incentive Payment System performance feedback and final scores for the 2025 performance year. The 2025 final score determines the payment adjustment eligible clinicians and group practices will receive in 2027, and 2027 MIPS payment adjustments will be available in approximately one month. If an eligible clinician or group practice believes CMS calculated their final score or 2027 payment adjustment incorrectly, they must file a targeted review with CMS within 60 days. How the Targeted Review Window Works The targeted review window opened with the release of final scores and will close 30 days after the release of MIPS payment adjustments. CMS will announce the release of payment adjustments through the QPP listserv in approximately one month. CMS generally requires documentation to support a targeted review request, which varies by circumstance, and a CMS representative will contact applicants about any specific documentation required. If a targeted review request is approved and results in a scoring change, CMS will update the final score and, if applicable, the associated payment adjustment as soon as technically feasible. Common Reasons to File a Targeted Review Data were submitted under the wrong Tax Identification Number or National Provider Identifier. The clinician has Qualifying APM Participant status and shouldn't receive a MIPS payment adjustment. Performance categories weren't automatically reweighted despite qualifying for reweighting due to extreme and uncontrollable circumstances. How to Request a Targeted Review Sign in at qpp.cms.gov using HARP credentials, or ACO-MS credentials for Shared Savings Program ACOs — the same credentials used to submit 2025 MIPS data. Then click "Targeted Review" in the left-hand navigation. Source: American Medical Association, Centers for Medicare & Medicaid Services, Quality Payment Program
