What to do
Check whether your state mandates the coverage
The federal rule removed an EHB requirement. It did not stop states from requiring coverage. Colorado is the clearest example.
Read your own policy, not the headlines
A plan may cover this care voluntarily as a non-EHB benefit. What your Evidence of Coverage says about your policy beats what the rule says about the category.
If the denial cites the EHB rule, check that it applies to you
The rule reaches non-grandfathered individual and small-group coverage. If your plan is not in that category, the citation is wrong.
Appeal on the ground the denial actually stated
A benefit-design exclusion and a medical-necessity denial are different arguments. Answer the one you were given.
Ask the state insurance department whether the exclusion is permitted
Where a state mandate exists, a policy exclusion may be unenforceable, and the regulator is who says so.
This is the fastest-moving page on the site
The rule is in effect because a court declined to pause it, not because a court upheld it. Summary judgment briefing has closed and a decision could change the position. Anything you read about marketplace coverage, here or elsewhere, needs a date attached to it before you rely on it.
Common questions
- Does this mean marketplace plans cannot cover gender-affirming care at all?
- No. It means the care cannot be counted as an essential health benefit. A plan may still cover it, and a state may still require it.
- Does a state mandate override the federal rule?
- States retain the ability to mandate benefits, subject to rules about who pays for mandates that exceed the federal baseline. Ask your state insurance department how it applies to your plan.
Where to go next
Sources for the legal points on this page
- The CMS essential-health-benefit exclusion is in effect for plan year 2026
Federal — individual and small-group ACA plans · effective plan year 2026
45 CFR 156.115(d), current text, definition at 156.400 (amendment history: 90 FR 27223, 25 June 2025; 91 FR 29874, 20 May 2026). Litigation: State of California v. Kennedy, No. 1:25-cv-12019 (D. Mass.) — docket NOT checked
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
- Colorado includes gender-affirming care in its essential-health-benefit benchmark
Colorado — individual and small-group · effective 2023-01-01
CMS press release, Coverage of LGBTQ+ Care as an Essential Health Benefit in Colorado (cms.gov) — procedure list and 1 Jan 2023 effective date confirmed verbatim; CMS benchmark summary documents run through plan years 2025-2027
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
- The ACA appeal framework: internal appeal, then binding external review
Federal — non-grandfathered group health plans and issuers · effective in force
29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06