Breaking: CMS Proposes Two Rules to Further Limit Youth Access to Gender-affirming Care

In a move aligned with a broader push to curb gender-affirming care for minors, the Centers for Medicare and Medicaid Services unveiled two proposed rules on December 18, 2025. one targets hospitals via revised Conditions of participation (cops), while the other would bar federal Medicaid and CHIP funds from covering the same services for youth. The proposals would affect a relatively small number of young people but could reshape access nationwide.

The packages come after a string of federal actions aimed at restricting gender-affirming care. An executive order issued in January 2025 called for steps to end such care for youth, including within Medicaid. In April and May 2025, CMS and the Department of Health and Human Services circulated letters urging states and providers to slow or move away from gender-affirming medical treatments for minors. The rules would not take effect instantly; the public would have a 60-day window to comment, after which CMS could finalize the text, possibly with changes or not at all. Legal challenges are anticipated,possibly delaying implementation.

The Proposed Conditions of Participation (CoPs) Rule

If finalized, the hospital cops rule would bar most Medicare- and Medicaid-participating hospitals from delivering certain gender-affirming medical services to patients under 18. Services listed include puberty blockers,hormone therapy,and,in rare cases,surgery. The restriction is based on facility type (hospitals), not payer, and would apply to all under-18 patients regardless of insurance type or payment method. Outside hospitals, other care settings could still provide gender-affirming care under existing CoPs for those providers.

Current CoPs regulate safety, quality, staffing, and administration. The proposed change marks a shift toward using hospital-level standards to limit a specific category of care. Hospitals would remain subject to routine safety requirements and could be cited for violations, with termination from Medicare/Medicaid as a last resort if violations persist. The proposal would affect an estimated 4,832 hospitals nationwide that are Medicare/Medicaid-certified under the relevant rules.

Data show hospitals have recently faced growing regulatory uncertainty around gender-affirming care. A number of large centers have already paused certain treatments amid evolving guidance and possible federal pressure. If adopted, the rule would likely push patients to choice care settings, potentially increasing travel times and costs for families.

The Proposed Medicaid Rule

The second rule would prohibit federal Medicaid and CHIP funds from covering the specified gender-affirming services for minors. Unlike the CoPs rule, this measure targets funding, not the provider type. Coverage would be blocked for those under 18 when funded by federal dollars,though states could continue to cover these services with state funds. Private insurers and non-federal funding could still cover related care such as psychotherapy, which is often part of gender-affirming care for youth.

The proposal notes that most of the related spending in 2023 occurred among older teens and was largely nonsurgical. The CMS analysis estimates about $31 million in Medicaid and CHIP spending for individuals under 18 on these services in 2023, representing a tiny share of overall Medicaid spending. Some states already restrict coverage for gender-affirming care; the rule would let states decide whether to use state dollars to fund any services not covered by federal funds.

As with the CoPs rule, the medicaid proposal does not indicate how many individuals would be directly affected, but emphasizes that utilization of gender-affirming medical services among adolescents remains relatively rare. The majority of spending on these services is nonsurgical, and two-thirds of the spending under 18 occurred among ages 15-18.

Looking ahead and Implications

If both rules are finalized after the comment period, access to gender-affirming care for youths could be constrained further, particularly for families with limited resources or those relying on Medicaid/CHIP. The most advantaged patients-those with private insurance or greater means to travel-could navigate the system more easily, while others may find access increasingly challenging. Critics warn that restricting access could have negative health outcomes, given research linking denial of care to worsened mental health and increased suicidality among transgender youth. Proponents argue that the measures reflect policy priorities at the federal level.

Advocacy groups have signaled intent to challenge the rules in court, arguing that the proposals intrude on clinical decision-making and patient-physician relationships. Civil rights and healthcare organizations are expected to file lawsuits on various legal theories if the rules move forward.

Key Facts At a Glance

health, Legal, and Social Context

Experts warn that access to gender-affirming care for youth is linked to better well-being when care is provided. Denial or delays can be associated with adverse mental health outcomes in some studies.Critics argue that policy changes should be grounded in solid clinical evidence and patient-centered care, rather than political considerations.The proposed measures are expected to trigger litigation across multiple legal avenues, including constitutional and administrative-law challenges.

For readers seeking broader context,coverage of executive actions and state-level policies related to LGBTQ health remains active in policy and public health discussions. Health systems and patient advocates are closely watching how these federal proposals interact with state laws and private coverage decisions.

what Comes Next

The public comment window will close after the 60-day period, with CMS weighing feedback before deciding on final form. If enacted,both rules would enter a legal and regulatory phase that could include court challenges,potential delays,and varying state implementations. the coming months will determine how aggressively- or whether-these rules reshape access to gender-affirming care for youth across the country.

What is your take on these proposed changes? Do you think hospital-based restrictions or funding bans would meaningfully improve safety, or could they limit necessary, evidence-based care for some youths? How should policymakers balance protection, medical guidance, and patient rights in this debate?

Share your views in the comments below and tell us how you think families might navigate these proposals. Do you expect states to respond with alternative funding or expanded private coverage to protect access?

Disclaimer: This article covers policy developments in health care and law. For medical decisions, consult qualified health professionals.This report does not constitute medical advice or legal counsel.

Further reading: policy updates and expert analyses from major health organizations and policy trackers as federal actions unfold.

Engage with us: share this breaking update, leave a comment with your perspective, and subscribe for ongoing coverage on health policy and youth care.