--- title: "Gender-Affirming Care May Lose Federal Coverage Protections in 2026" slug: "250912-gender-affirming-care-federal-protections" date: "2025-09-12" author: "FHI Team" description: "CMS final rule removes 'specified sex-trait modification procedures' from essential health benefits for ACA marketplace plans starting Plan Year 2026." tags: ["gender-affirming-care", "aca", "marketplace", "essential-health-benefits", "cms", "insurance-coverage", "transgender-healthcare"] readTime: "4 min read" --- If you rely on ACA marketplace health insurance for gender-affirming care, a major change is scheduled for plan year 2026. CMS has [finalized](https://www.federalregister.gov/documents/2025/06/25/2025-11606/patient-protection-and-affordable-care-act-marketplace-integrity-and-affordability) the Marketplace Integrity & Affordability rule, which removes from required EHB coverage “specified sex‑trait modification procedures” as Essential Health Benefits (EHBs) starting in PY 2026. This category includes pharmaceutical (e.g., hormones when used for gender transition) and surgical interventions provided for the purpose of aligning physical appearance with an asserted identity different from one’s sex. Changes to gender-affirming care coverage under new federal rules This doesn't ban coverage. But it means [plans](https://www.them.us/story/trump-trans-health-care-benefits-costs) that keep covering gender-affirming care can set higher out-of-pocket costs, impose stricter approval processes, or drop coverage entirely. You also won't get the same cost-sharing protections you currently have for EHBs, like having expenses count toward your deductible and out-of-pocket maximum. In addition, premiums and cost sharing attributable to non‑EHB services aren’t eligible for APTC/CSR subsidies and may be subject to annual/lifetime dollar limits. People in some states (for example, California, Colorado, Vermont, and Washington) may still have [protections](https://shvs.org/new-federal-rules-affecting-coverage-of-treatment-for-gender-dysphoria-considerations-for-states/) because state law or benchmark‑plan policy requires coverage of medically necessary gender‑affirming care. Where a state mandates this coverage for ACA plans after PY 2025, the services would be covered as non‑EHB and the state must defray the added cost under 45 C.F.R. §155.170. New Mexico also has legal protections that support access to gender‑affirming care, though the specific coverage requirements may differ from states with explicit ACA mandates. ## What You Can Do Now - **Check Your State's Rules**: Look up your state's ACA "benchmark plan" and laws. If your state mandates gender-affirming care coverage, your protections remain intact. State insurance department websites often have this information. - **Review Your Current Plan's Policy**: Read your plan's benefits booklet or call customer service to confirm how it covers gender-affirming services now. - **Know Your Appeal Rights**: If a service is denied, you can file an appeal. Fight Health Insurance can help you write an appeal to fight a health insurance denial. - **Track Ongoing Litigation**: Some portions of the Marketplace Integrity & Affordability rule were temporarily paused by a federal court on August 22, 2025. The EHB change for PY 2026 remains scheduled unless a court blocks it—check back for updates before Open Enrollment. ### References - [CMS Final Rule on ACA Marketplace Integrity and Affordability](https://www.federalregister.gov/documents/2025/06/25/2025-11606/patient-protection-and-affordable-care-act-marketplace-integrity-and-affordability) - [Analysis of Trans Health Care Coverage Changes](https://www.them.us/story/trump-trans-health-care-benefits-costs) - [CMS Fact Sheet: 2025 Marketplace Integrity & Affordability Final Rule](https://www.cms.gov/newsroom/fact-sheets/2025-marketplace-integrity-and-affordability-final-rule) - [Explainer: Potential Changes to ACA Coverage of Gender-Affirming Care](https://www.kff.org/private-insurance/new-rule-proposes-changes-to-aca-coverage-of-gender-affirming-care-potentially-increasing-costs-for-consumers/) - [State Considerations for Gender Dysphoria Coverage Rules](https://shvs.org/new-federal-rules-affecting-coverage-of-treatment-for-gender-dysphoria-considerations-for-states/) - URL: https://www.fighthealthinsurance.com/blog/250912-gender-affirming-care-federal-protections/ - Site index for agents: https://www.fighthealthinsurance.com/llms.txt