What is changing in the rules right now

What we have written down

Dated notes on the changes that reach this site’s readers, newest first. Each says what happened, what it does not do, and where to check it. Subscribe by RSS.

1. 13 August 2026#

   A report on billing codes, not a rule — but get your diagnosis documented now

   HHS released a commissioned report analysing 2015–2025 insurance claims, alleging that puberty blockers for minors were billed under endocrine diagnosis codes rather than gender-dysphoria ones — around $50m under E34.9 and $11m under E30.1 for ages 13 to 17. The release states that named hospitals and clinics were referred to the Department of Justice and the HHS Office of Inspector General.

   The practical consequence for a patient is attention on those codes. If you or your child take a GnRH agonist for a reason that is not gender dysphoria — precocious puberty, endometriosis, fibroids, prostate cancer — it is worth having the diagnosis documented in your own records now rather than at the point a claim is questioned. OPM told federal carriers in August 2025 not to exclude whole classes of drugs for exactly this reason.

   What it does not do. It is a report and a referral, not a rule. It changes no coverage requirement, creates no new exclusion, and does not itself make any care unlawful. Nothing in it is addressed to adults.

   HHS press release, 13 August 2026MedicaidRead a denial letter
2. 13 August 2026#

   Medicaid and CHIP: if you are already on hormones, your date is April, not October

   CMS published the final rule in the Federal Register. Federal Medicaid dollars may not pay for what the rule calls sex-rejecting procedures for anyone under 18, and federal CHIP dollars for anyone under 19. The two ages are genuinely different, so check which programme you are in before working out whether it reaches you.

   There is a wind-down, and it is narrower than it sounds. For beneficiaries already receiving cross-sex hormone therapy, states may keep claiming federal money for those medications for up to six months from the effective date — so into roughly April 2027. If that is you, the date to plan around is the end of that window, not October.

   Puberty blockers do not get that runway, and neither does surgery. The rule says so directly: the tapering provision covers cross-sex hormone therapy only, and federal money for blockers and for surgery stops on the effective date itself. CMS's stated reason is that blocker effects are treated as reversible on stopping. So the group of people whose date is April is smaller than the wind-down first appears — everyone else's date is 13 October 2026.

   What it does not do. It governs what federal money pays for. It does not make the care unlawful, it does not reach private insurance or employer plans, and it does not stop a state spending its own money — what your state does next is a separate question with a separate answer in each state.

   Source: Medicaid Program: Prohibition on Federal Medicaid and Children's Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children, CMS, FR Doc 2026-16508, filed 11 August 2026, publication 13 August 2026MedicaidWhat's changing
3. 31 July 2026#

   External review is running again — and a deadline you missed in July runs to 2 October

   External review is the step where an independent organisation, not your insurer, decides your appeal — and its decision binds the plan. The federal version of it was unavailable from 1 July 2026 and reopened on 31 July.

   If your deadline to request one fell between 1 July and 3 August 2026, you now have until 2 OCTOBER 2026 to file. That is the whole point of this note: the extension expires, and nobody will remind you. If you sent a request before 1 July and have heard nothing, you do not need to send it again.

   This is the HHS-run process, used where a state has no process of its own: Alabama, Florida, Georgia, Texas, Wisconsin, American Samoa, Guam, the Northern Mariana Islands and the US Virgin Islands — and by self-insured state or local government plans that chose it. Requests go to MAXIMUS, the contractor that runs it.

   What it does not do. It does not change any other deadline. Your internal appeal clock is untouched, and if your state runs its own external review — most do — none of this applied to you in the first place. It also does not reopen a review that was already decided, and it is not a second chance for a deadline that passed before 1 July 2026.

   Source: CMS, HHS-administered Federal External Review Process Deadline Extension, https://www.cms.gov/files/document/hhs-administered-ferp-deadline-extension-07-31-26.pdf — read in full 2026-08-14. Statutory framework at 45 CFR 147.136(a)(1)(i), which provides a Federal external review process for plans and issuers not subject to an applicable State processExternal reviewHow appeals work
4. 16 June 2026#

   A court struck down nine parts of the marketplace rule — your exclusion was not one of them

   On 12 June 2026 a federal court in Maryland set aside part of the 2025 Marketplace Integrity and Affordability rule, and on 16 June it amended that order to its final shape: nine provisions vacated. They are the ones that made enrolling harder — the shortened open enrollment period starting in 2027, the five-dollar premium charge on people automatically re-enrolled, the loss of guaranteed coverage for people with past-due premiums, and five separate income-verification and reconciliation changes.

   The provision barring plans from counting sex-trait modification procedures as an essential health benefit was not among them. We read the order and searched the full sixty-one-page opinion: it does not contain the phrase sex-trait, or transgender, or the section number, anywhere. That exclusion is in force today, for plan years beginning in 2026 and again for plan years beginning on or after 1 January 2027.

   One detail is worth having if you read the order yourself. The vacated list does cite 45 CFR 156.400 — but only for a change to actuarial-value ranges, not for the sex-trait modification definition the same section carries. Seeing that number on the list and stopping there is the easiest wrong turn available here.

   What it does not do. The vacatur changes nothing about what your plan must cover for this care. It is also not a ruling that the exclusion is lawful: the court was not asked about it and did not decide it. The case over the exclusion itself is separate — State of California v. Centers for Medicare & Medicaid Services, 1:25-cv-12019 in Massachusetts, argued 29 July 2026 with no decision yet. And the nine vacated provisions are not settled either: the government appealed on 16 July 2026 and the Fourth Circuit has the case.

   Source: 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 LOCATED AND READ 2026-08-14: State of California v. Centers for Medicare & Medicaid Services, No. 1:25-cv-12019 (D. Mass.), Judge Nathaniel M. Gorton, filed 17 July 2025. Docket entry 105, 1 October 2025, quoting the order: MEMORANDUM AND ORDER — the motion of plaintiffs for a preliminary injunction (Docket No. 5) is DENIED. Cross-motions for summary judgment (105, 120, 123) were argued at a hearing held 29 July 2026 and no merits decision has issued.Source: City of Columbus v. Kennedy, No. 1:25-cv-02114-BAH (D. Md.), Judge Brendan A. Hurson — ECF 73 (memorandum opinion, 61 pp., 12 June 2026), ECF 74 (order, 12 June 2026), ECF 76 (order granting ECF 75 consent motion to clarify and amending ECF 74 as clarified, 16 June 2026), ECF 79 (notice of appeal, 16 July 2026), ECF 81 (USCA No. 26-1938, 4th Cir., docketed 21 July 2026). Rule vacated in part: 90 FR 27074.Marketplace / ACABlanket exclusion
5. 15 May 2026#

   If your clinic stopped and no rule changed, look for a settlement, not a coverage rule

   On 15 May 2026 the Justice Department announced a settlement with Texas Children's Hospital, reached with the Texas Attorney General: ten million dollars, plus money for care for detransitioners, plus a commitment to stop performing these procedures on children. DOJ describes it as the first resolution under an ongoing national investigation, so more are likely and some have been reported.

   The legal theory is billing, not coverage. The allegations are that the hospital submitted false billings to public and private payors to get the care covered, under the False Claims Act, the food and drug law, and federal fraud and conspiracy statutes. DOJ's own announcement says the claims are allegations only, that there has been no determination of liability, and that the hospitals denied them.

   That distinction is the practical point. If a clinic near you stopped taking appointments and you could not find a rule that changed, this is a likelier explanation than a coverage change — and it means the thing that moved was one institution's decision, not your plan's obligations.

   What it does not do. A settlement binds the institution that signed it and nobody else. It changes no coverage requirement, creates no exclusion, and makes no care unlawful. The published terms concern patients under 18. We have read DOJ's announcement of this one settlement in full and nothing else: other settlements have been reported, and we have not verified their terms, dates or amounts, so do not take any figure for them from us.

   Justice Department press release, 15 May 2026Proving availabilityMedicaid
6. 18 April 2026#

   A court struck down the HHS declaration — which does not reopen the clinics it closed

   On 18 December 2025 the HHS Secretary issued a declaration saying that what it calls sex-rejecting procedures for children and adolescents are neither safe nor effective, and so fail professionally recognised standards of health care. CMS has since spelled out what that was for: it is a ground on which a provider can be shut out of federal health programmes altogether.

   A federal court in Oregon held the Secretary had no authority to issue it, vacated it on 18 April 2026, and permanently barred HHS from relying on it. The bar runs only against providers in the states that brought the case, and CMS records a pending motion to change the judgment. All of that is CMS's own account, in a rule it published on 13 August 2026.

   What it does not do. The declaration was about children and adolescents; it said nothing about adults. Vacating it does not undo the closures it caused — hospitals stopped programmes while it stood, and a court order does not restart them. We did not obtain the court's judgment itself, only CMS's description of it, so the date and the terms come from the Federal Register rather than from the docket. If your clinic stopped, ask them directly what their position is now.

   Source: 91 FR 52406 at 52406-52407 (FR Doc 2026-16508, 13 Aug. 2026), quoting the Declaration of 18 Dec. 2025 and citing Oregon v. Kennedy, No. 6:25-cv-2409-MTK (D. Or.), ECF No. 94 (Apr. 18, 2026) and ECF No. 96; exclusion mechanism at 42 U.S.C. 1320a-7(b)(6)(B), 42 CFR 1001.2 and 1001.701MedicaidProving availability
7. 31 March 2026#

   Federal employees: 2026 is the last year you can ask for the mid-treatment exception

   If you are in FEHB or PSHB, this care has been excluded since plan year 2026, but one route stayed open: carriers had to run an exceptions process for enrollees already part-way through a surgical or hormonal regimen for diagnosed gender dysphoria. On 31 March 2026 OPM told carriers to take it away, in those words — beginning in the 2027 plan year, carriers must remove any exceptions process.

   So 2026 is the last plan year that route exists. If you are mid-regimen, use it now, ask for it by name, and get the carrier's answer in writing. When the 2027 brochures post at open season, read your own brochure rather than assuming either way: the brochure term is what governs your claim, not a letter to carriers.

   Counselling survives. The same instruction says counselling for possible or diagnosed gender dysphoria must still be covered, by a licensed mental health provider.

   What it does not do. It reaches FEHB and PSHB only — not TRICARE, not the VA, not Medicaid, not Medicare, not marketplace plans, and no private, state or local employer plan. It does not create the exclusion either; the August 2025 letter did that, for all ages. If you are arguing about the exclusion itself, cite that one, and cite this one only for the loss of the exception. It does not revoke an exception already granted for 2026, and no 2027 brochure exists yet for anyone to have read.

   Source: OPM FEHB Program Carrier Letter 2025-01b (15 August 2025), Chemical and Surgical Sex-Trait Modification Services for Plan Year 2026 Proposals; Carrier Letter 2025-01a (31 January 2025); Carrier Letter 2026-07 (31 March 2026), which removes the exceptions process beginning Plan Year 2027Source: OPM FEHB Program Carrier Letter 2026-07 (31 March 2026), section headed Sex Rejection Treatments — https://www.opm.gov/healthcare-insurance/carriers/fehb/2026/2026-07.pdfSelf-funded, non-ERISAHow appeals work
8. 10 March 2026#

   In five states, Section 1557 no longer answers a Medicaid surgery exclusion

   On 10 March 2026 a federal appeals court held that West Virginia Medicaid may exclude gender-affirming surgery. Three judges decided it unanimously, after the Supreme Court sent the case back to be reconsidered in light of its 2025 decision in United States v. Skrmetti. Their reasoning is that the exclusion sorts by medical diagnosis rather than by sex or transgender status, so on its face it does not discriminate.

   The half that reaches furthest is the second holding: the same reasoning means the exclusion does not violate Section 1557, the health-care nondiscrimination statute. If you are in Maryland, North Carolina, South Carolina, Virginia or West Virginia, an appeal resting mainly on 1557 now runs into a published decision against it, and the weight has to move to your plan's own wording, to medical necessity, and to state law.

   What it does not do. It binds courts in five states and nowhere else, and it is not a Supreme Court ruling. The exclusion it upheld covers SURGERY only — West Virginia went on covering hormone therapy and psychotherapy — so it is not authority for dropping those. It decides nothing about employer plans, marketplace plans or Medicare, and the court expressly declined to say whether transgender people are a protected class. We have not confirmed whether anyone has asked the Supreme Court to take it, so do not treat it as the last word.

   Source: Anderson v. Crouch, No. 22-1927 (4th Cir. Mar. 10, 2026) (published) — read from the opinion text, CourtListener cluster 10807487, verbatim at both the Equal Protection and the Section 1557 holdingsMedicaidBlanket exclusion
9. 19 December 2025#

   The hospital rule you have been warned about is still a proposal, and it binds nobody

   On 19 December 2025 CMS proposed a condition of participation that would bar a hospital from performing what it calls sex-rejecting procedures on anyone under 18, with Medicare and Medicaid participation as the lever. Comments closed on 17 February 2026.

   As of 14 August 2026 there is no final rule. We checked it the way that can actually come back negative: by asking the Federal Register for every document ever published under this rule's own identifying number, rather than searching for its title. One document exists, and it is the proposal. A proposal imposes nothing, so nothing has changed for any patient because of this docket.

   What it does not do. This is not the Medicaid and CHIP funding rule, which IS final and takes effect on 13 October 2026, and it is not the HHS declaration an Oregon court vacated in April 2026. Coverage merges the three, and they are three different instruments with three different reaches. If this one is ever finalised it would reach hospitals, and so patients under 18 whoever is paying; today it reaches nobody. And this is a snapshot of what has PUBLISHED, taken on one day — we did not check whether a final rule is sitting at White House review, which is where one waits before it appears.

   Source: 90 FR 59463 (19 Dec. 2025), FR Doc 2025-23465, docket CMS-3481-P, RIN 0938-AV87, 42 CFR part 482; comments closed 17 Feb. 2026. Negative verified by Federal Register API query on regulation_id_number 0938-AV87, which returns one document (the proposal).MedicaidWhat's changing
10. 22 October 2025#

    The 2024 rule naming gender identity is gone — the statute is not, so stop citing the rule

    In 2024 HHS wrote a rule saying that the ban on sex discrimination in Section 1557 covers gender identity. A federal court in Mississippi vacated those parts of it on 22 October 2025, and HHS has since said it treats them as legally void and will not enforce them.

    That matters because a lot of appeal letters were built on that rule by name. If yours cites the 2024 regulation, the reviewer can now say the provision no longer exists — so make the argument from the statute and from your plan's own wording instead.

    What it does not do. It does not repeal Section 1557 itself. The statute is unchanged, the rest of the 2024 rule remains in force, and state nondiscrimination law is separate and untouched — a state insurance mandate does not stop applying because a federal rule was vacated. What went is one regulation's explicit wording, not the underlying law. But read the March 2026 Fourth Circuit note below before leaning on the statute: in Maryland, North Carolina, South Carolina, Virginia and West Virginia there is now a published decision holding that a diagnosis-framed exclusion does not violate 1557.

    Source: 91 FR 32887 (2026-06-02), FR Doc 2026-11015 — Notice of Vacatur; Tennessee v. Kennedy, No. 1:24-cv-161-LG-BWR (S.D. Miss. Oct. 22, 2025); vacated rule at 89 FR 37522 (2024-05-06)Blanket exclusionState mandates
11. 9 September 2025#

    In three states, an employer exclusion is not discrimination on its face

    Anna Lange, a sheriff's deputy in Houston County, Georgia, won at trial against her employer's health plan, which excludes services for a sex change. On 9 September 2025 the full Eleventh Circuit reversed, 8 judges to 5, holding the exclusion is not discrimination on its face under Title VII because it draws a line between treatments rather than between people.

    The case was sent back, not ended. The trial judge had already found a genuine dispute about whether the county adopted and kept the exclusion for discriminatory reasons, nobody appealed that finding, and the appeals court said in terms that it was outside what it was deciding.

    What it does not do. It binds courts in Alabama, Florida and Georgia only. It is an employment case — it decides nothing about Medicaid, Medicare, marketplace plans, Section 1557 or the Constitution, and Title VII only reaches employers with 15 or more employees. It does not hold that such an exclusion is lawful whatever the reason behind it; it holds that the wording alone is not proof of a bad one. And do not read the remand as a promise: a judge who voted with the majority wrote separately that the decision leaves Lange with no practical remedy.

    Source: Lange v. Houston County, No. 22-13626 (11th Cir. Sept. 9, 2025) (en banc) — read from the opinion text, CourtListener cluster 10668627Self-funded, private employerBlanket exclusion
12. 15 August 2025#

    Federal employee plans dropped this coverage for 2026 — at every age, not just under 19

    OPM Carrier Letter 2025-01b tells FEHB and PSHB carriers that for Plan Year 2026 they will no longer cover chemical or surgical modification of sex traits, and that this applies regardless of age. The January letter it supersedes had reached only under-19s.

    Three things in that letter are worth more to an enrollee than the headline. Carriers MUST establish an exceptions process for people mid-treatment in a surgical or hormonal regimen, and must publish the details in their brochures. Counselling for gender dysphoria must still be covered. And carriers were told not to exclude whole classes of drugs, so a GnRH agonist prescribed for endometriosis or cancer is not within the exclusion.

    What it does not do. It is guidance to carriers about the federal civilian plans only. It does not touch TRICARE, the VA, Medicaid, Medicare, marketplace plans, or any private employer plan. If you work for a city, a state, a school district or a church, it is not about you.

    Source: OPM FEHB Program Carrier Letter 2025-01b (15 August 2025), Chemical and Surgical Sex-Trait Modification Services for Plan Year 2026 Proposals; Carrier Letter 2025-01a (31 January 2025); Carrier Letter 2026-07 (31 March 2026), which removes the exceptions process beginning Plan Year 2027Self-funded, non-ERISA
13. 25 June 2025#

    Your marketplace plan can still cover this care and leave your costs uncapped

    A CMS rule bars issuers from including what it calls specified sex-trait modification procedures in essential health benefits, for plan years beginning in 2026 and again for those beginning on or after 1 January 2027.

    The trap is that this is not the same as an exclusion. A plan can still cover the care voluntarily, and a state can still require it — but covered as a NON-essential benefit it stops carrying the essential-benefit protections. CMS said so itself when it made the rule: the ban on annual and lifetime dollar limits goes, and what you pay stops counting toward your out-of-pocket maximum. CMS put that consequence beyond the individual market too, naming large-group and self-insured plans.

    States are suing over it. The judge declined to put the rule on hold while the case runs, so it is in force now; the arguments that will decide it were heard on 29 July 2026 and no decision has come. The case is State of California v. Centers for Medicare & Medicaid Services, 1:25-cv-12019 in the federal district court in Massachusetts, and the docket is public.

    What it does not do. It does not reach self-funded employer plans, Medicaid or Medicare, and it does not make the care unlawful or stop any plan choosing to cover it. It also does not override a state mandate. And it is not settled: a group of states is challenging it, the judge refused to block it while the case runs (1 October 2025), and the arguments that decide it were heard on 29 July 2026 with no ruling yet. So the rule applies today and could change.

    Source: 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 LOCATED AND READ 2026-08-14: State of California v. Centers for Medicare & Medicaid Services, No. 1:25-cv-12019 (D. Mass.), Judge Nathaniel M. Gorton, filed 17 July 2025. Docket entry 105, 1 October 2025, quoting the order: MEMORANDUM AND ORDER — the motion of plaintiffs for a preliminary injunction (Docket No. 5) is DENIED. Cross-motions for summary judgment (105, 120, 123) were argued at a hearing held 29 July 2026 and no merits decision has issued.Source: 90 FR 27074, at 27161 (response to comments) and at 27204 (Regulatory Impact Analysis section 14); operative rules at 45 CFR 156.115(d), 156.400, 147.126, 156.130, 156.125Marketplace / ACABlanket exclusion
14. 15 May 2025#

    The newer parity rule is paused — the duty your appeal actually uses is not

    Federal agencies said in May 2025 that they will not enforce the new parts of the 2024 mental-health parity rule while litigation runs. Parity is the rule that a plan may not treat mental-health and substance-use benefits worse than medical ones.

    What survives is the part most appeals actually use: the 2013 rules, the plan's duty to produce a written comparative analysis when it applies a non-quantitative limit, your right to demand that analysis, and your right to sue. Ask under those rather than under the 2024 rule by name.

    What it does not do. It does not repeal anything. The statute stands, the 2013 rules stand, and the 2024 rule is still in the regulation text — it was paused, not removed. Note also that we could not locate the non-enforcement announcement in the Federal Register: it appears to be sub-regulatory, so that half is reported rather than verified, while the duties that survive were read from the regulation directly.

    Source: 29 CFR 2590.712 and 2590.712-1 — current text still carries the 2024 rule (definitions keyed to 22 November 2024), so the rule was not rescinded. The May 2025 non-enforcement policy is sub-regulatory and was NOT located in the Federal Register, so it remains unverifiedParity (MHPAEA)Not medically necessary
15. 17 March 2025#

    The VA stopped starting new care — the two written exceptions are what to check

    VHA Notice 2025-01(1) rescinded the 2018 directive on care for transgender and intersex veterans. Cross-sex hormone therapy continues only for veterans already receiving it from the VA on 17 March 2025, or who were receiving it at separation from military service. The notice also states flatly that the VA does not provide any other medical or surgical therapy for gender dysphoria.

    If you are inside one of those two exceptions, you are relying on something written down rather than asking a favour, and it is worth saying so in those words.

    What it does not do. It does not touch the rest of your VA care. The same notice preserves comprehensive health care including preventive and mental health care for veterans with gender dysphoria. It also has nothing to do with TRICARE, which is a separate system for serving members, retirees and families.

    Source: VHA Notice 2025-01(1), 17 March 2025, Rescission of VHA Directive 1341(4); 38 CFR 17.38(c)(4) excludes "gender alterations" from the VA medical benefits packageVA (veterans)TRICARE (military)
16. 28 January 2025#

    Federal reviewers were told WPATH is not authority — do not let a letter rest on it alone

    Section 3(a)(i) of Executive Order 14187 directs that agencies "shall rescind or amend all policies that rely on WPATH guidance, including WPATH's Standards of Care Version 8". That is the document most surgery letters and most medical-necessity arguments are built on.

    If your appeal goes to a federal programme — Medicaid, Medicare, TRICARE, the VA, or a federal employee plan — assume the reviewer has been told not to treat WPATH as authority, and do not let it carry the argument alone. Cite the underlying clinical literature, your own surgeon's and prescriber's reasoning, and the plan's own written criteria. A letter that says "this meets WPATH SOC-8" and stops has put everything on the one source the order names.

    What it does not do. It does not bind private insurers, employer plans or marketplace plans, which are not agencies — for those a WPATH-based letter remains ordinary, expected evidence. It does not make the standards wrong, withdraw them, or stop your clinicians following them, and it does not stop you citing them. It changes who is obliged to treat them as authoritative, not whether they are good medicine.

    Source: EO 14187, 90 FR 8771 (3 Feb 2025), FR Doc 2025-02194 — sec. 2(a) definition of child, sec. 6 TRICARE, sec. 7 FEHB and PSHBWPATH lettersSurgery letter contents
17. 28 January 2025#

    An order told the Pentagon to cut under-19 TRICARE — ask your contractor what it applies today

    Executive Order 14187 directs the Secretary of Defense to commence a rulemaking or sub-regulatory action excluding what it calls chemical and surgical mutilation of children from TRICARE coverage, and to amend the TRICARE provider handbook. Its section 2(a) defines a child as anyone UNDER 19 — a year above the age of majority — so an 18-year-old adult dependent falls inside it.

    We could not confirm that the rulemaking has published. A Federal Register search on 13 August 2026 found no resulting rule, and sub-regulatory action such as a handbook or policy-manual change would not necessarily appear there at all. That is a reason to ask your regional contractor in writing what policy they are applying to your claim today, rather than to assume either way.

    What it does not do. It is not the reason TRICARE does not cover gender-affirming surgery. That exclusion is much older, sits in 32 CFR 199.4(g)(29), and the regulation attributes it to statute rather than to any executive action. The order also says nothing about hormone therapy or mental health care for adults, and nothing about the VA, which is a separate system that changed separately in March 2025.

    Source: EO 14187, 90 FR 8771 (3 Feb 2025), FR Doc 2025-02194 — sec. 2(a) definition of child, sec. 6 TRICARE, sec. 7 FEHB and PSHBTRICARE (military)VA (veterans)