KFF March 24, 2025
Lindsey Dawson, Kaye Pestaina, Matthew Rae

March 10th, CMS issued a proposed rule that seeks to change how plans sold on and off the Affordable Care Act’s (ACA) Marketplaces (plans for individuals and small businesses), would cover gender affirming care services, which the rule calls “coverage for sex-trait modification1.” The rule proposes, beginning plan year 2026, to prohibit insurers from covering gender affirming care as an essential health benefit (EHB), which could lead insurers to drop coverage or shift costs to individuals and states.

Essential Health Benefits

The ACA requires non-grandfathered individual and small group health plans to cover a package of EHBs which must be “equal to the scope of benefits provided under a typical employer plan”, are protected by cost-sharing limits, and...

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Topics: ACA (Affordable Care Act), Insurance, Patient / Consumer
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