Commenting Toolkit | Centers for Medicare and Medicaid Services Proposed Rules Impacting Gender-Affirming Care

Comments on both rules are due February 15 by midnight ET through
Equality Connecticut’s secure portal

Ready to comment? Submit your comment(s) securely and privately through the portal

The Basics

On this page, you will find detailed information about the proposed rules and guidance for commenting. In short:

Commenting on proposed rules is important because it gives the public a formal, legally recognized way to influence what the final policy looks like—and whether it moves forward at all. They are one of the most effective tools we have to slow, weaken, or stop harmful policies—and to protect access to care.

Before submitting a public comment, individuals should thoughtfully evaluate their personal and professional risk. Public comments play an important role in advocacy efforts and can be valuable in future legal challenges, but participation should only occur if it feels safe to do so. Providing identifying information may carry risks, including the possibility that individuals or locations named in a comment could be subject to scrutiny. Anonymous commenting is permitted. Equality Connecticut’s portal is a private and secure method for submitting your comment on the rules.

It is critical that your comment be unique. Please avoid using text pasted from a template; comments using the same language are bundled together and largely ignored by the Federal Register.

Have detailed questions? Need help?

Resources are available:
Webinar: Whether you are commenting individually or planning to attend a Crush the Comments social, this webinar will prepare you for what to expect. We’ll cover the basics of both proposed rules, their anticipated impact, best practices for commenting, and any questions. Registration is required

Office hours: For more individualized assistance, sign up for office hours hosted by Equality Connecticut.

Ready to comment? Submit your comment(s) securely and privately through the portal

Contents

Click on any of the subjects below to jump to that section.

Background

On December 18, 2025, the Centers for Medicare and Medicaid Services (CMS) released two proposed regulations that would further restrict access to gender-affirming medical care for minors. One proposal would revise hospital Conditions of Participation, effectively barring most hospitals that participate in Medicare or Medicaid from providing certain gender-affirming treatments to youth. The second proposal would prohibit the use of federal Medicaid and CHIP funds to cover gender-affirming care for this population.

If adopted, these changes would significantly limit access to care for adolescents, despite gender-affirming care being widely recognized as a best-practice model endorsed by major medical associations. Together, the proposals would meaningfully narrow the availability of medically recommended interventions.

These rules are consistent with a broader pattern of administrative actions aimed at restricting access to healthcare for youth. They build on a January 2025 executive order directing the Department of Health and Human Services (HHS) to pursue measures to end such care for adolescents, including through Medicaid, and explicitly identifying hospital Conditions of Participation as a potential mechanism. Additional steps followed in April 2025, when CMS issued guidance to state Medicaid directors emphasizing quality-of-care standards in a manner that appeared to encourage limits on gender-affirming care. In May 2025, HHS also circulated guidance to providers, state medical boards, and health system risk managers urging changes to clinical protocols away from gender-affirming treatment.

The proposed rules are not yet in effect. Each is subject to a 60-day public comment period which closes on February 17, 2026. After reviewing submitted comments, CMS may choose to finalize the rules as written, revise them, or decline to move forward. The proposed rules are already being challenged in court by 20 states. If finalized, we anticipate additional legal challenges, which could delay or prevent their implementation.

The Rules

1. “Hospital Condition of Participation: Prohibiting Sex-Rejecting Procedures for Children” (CMS-3481-P)(RIN 0938-AV73)

Summary

This proposed regulation would disqualify any hospital that offers puberty blockers, hormone therapy, or surgical procedures to transgender patients under the age of 18 from participating in Medicare or Medicaid—programs relied upon by nearly all hospitals nationwide. The rule does not appear to extend to freestanding clinics or to mental and behavioral health services provided in hospital-affiliated outpatient settings.

By inserting federal policy into clinical decision-making, the proposal transforms deeply personal medical care into a political issue. In doing so, the Centers for Medicare & Medicaid Services (CMS) dismisses both the lived experiences of transgender people and the substantial body of medical evidence showing that puberty blockers and hormone therapy—and, in limited circumstances, surgical interventions for older adolescents—can improve health outcomes for transgender youth.

The proposal suffers from several fundamental flaws:

Novel and unprecedented: CMS traditionally uses Conditions of Participation to establish baseline health and safety requirements for hospitals participating in Medicare and Medicaid. There is no precedent for deploying these standards to categorically prohibit licensed providers from offering widely recognized, evidence-based care to a specific minority population.

Contrary to scientific consensus: The rule disregards decades of peer-reviewed research supporting the safety and effectiveness of gender-affirming care for youth, while overstating potential risks. CMS relies heavily on a Department of Health and Human Services publication known as the “HHS Report,” which dismisses the benefits of affirming care and minimizes the well-documented harms of care denial. The report mischaracterizes the existing research base as unreliable, despite its breadth and consistency.

Internally inconsistent: The proposal includes explicit exceptions for medical interventions performed on intersex infants—procedures that are often nonconsensual, medically unnecessary, and associated with long-term harm. It also permits cisgender youth to receive the same medications and treatments when used to reinforce sex assigned at birth. Allowing these practices while penalizing care for transgender patients reveals the rule’s underlying purpose: to single out transgender youth for discriminatory treatment rather than to advance patient safety.

Legally vulnerable: Section 1801 of the Social Security Act expressly prohibits CMS from exercising supervision or control over the practice of medicine. To sidestep this limitation, CMS asserts that gender-affirming care for transgender youth does not constitute healthcare and therefore falls outside the practice of medicine. This reasoning is circular and unsupported. There is no credible legal or medical basis for excluding these treatments from the definition of medical practice.

2. “Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures furnished to Children” (CMS-2451-P) (RIN 0938-AV87)

Summary

The proposed regulation would prohibit the use of federal Medicaid funds to cover puberty blockers, hormone therapy, and surgical interventions for transgender patients under the age of 18, and would similarly bar Children’s Health Insurance Program (CHIP) funding for such care for transgender individuals under 19.

This proposal inserts political judgment into medical decision-making that should remain between patients, families, and clinicians. To support the restriction, the Centers for Medicare & Medicaid Services (CMS) discounts both the lived experiences of transgender people and the substantial body of evidence demonstrating that gender-affirming care can improve mental and physical health outcomes for transgender youth.

The proposal is undermined by several critical deficiencies:

Lack of scientific foundation: CMS asserts that there is insufficient high-quality evidence supporting the safety and effectiveness of gender-affirming care for youth, while simultaneously overstating potential risks. This conclusion relies heavily on a Department of Health and Human Services document referred to as the “HHS Report,” which minimizes documented benefits and disregards the well-established harms associated with denying care. The report mischaracterizes decades of peer-reviewed research as low quality without credible justification.

Internal inconsistencies: The rule includes explicit exceptions for medical procedures performed on intersex infants—interventions that are frequently nonconsensual, medically unnecessary, and associated with long-term harm. It also permits cisgender youth to receive the same medications and treatments when used to reinforce sex assigned at birth. Allowing these practices while prohibiting care for transgender patients reflects a discriminatory double standard rather than a principled assessment of medical risk.

Conflict with federal law: Medicaid and CHIP statutes require that services be delivered in the best interests of beneficiaries and in an effective, efficient, and coordinated manner. The proposed rule conflicts with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, which obligates states to cover medically necessary care for eligible children. It also runs afoul of Medicaid’s comparability requirement, which prohibits providing lesser coverage to one group than to others. CMS attempts to justify these departures by asserting—without adequate evidence—that gender-affirming care poses unique risks, while ignoring the documented harms of untreated gender dysphoria.

Mischaracterization of impact: CMS significantly understates the real-world consequences of the proposal. The analysis fails to account for the harms associated with denying care and inaccurately suggests that meaningful alternatives would remain available for affected families.

Commenting

Why is it important to comment?

Commenting on proposed rules is important because it gives the public a formal, legally recognized way to influence what the final policy looks like—and whether it moves forward at all. They are one of the most effective tools we have to slow, weaken, or stop harmful policies—and to protect access to care.

Here’s why it matters, especially in this moment:

It shapes the final rule:  Federal agencies are legally required to review and consider public comments before finalizing a rule. Substantive comments—those that raise legal, medical, economic, or implementation concerns—can lead agencies to revise, narrow, or withdraw proposals.

It builds the record for legal challenges:  Public comments become part of the official administrative record. If the rules are finalized and challenged in court, judges look closely at whether the agency adequately responded to concerns raised during the comment period. Strong comments help expose flaws, contradictions, and unlawful reasoning.

It demonstrates real-world impact:  Comments from individuals, families, providers, advocates, and organizations document how the proposed rules would affect people’s lives, health, and access to care. This evidence counters abstract or misleading claims made by the agency.

It forces accountability:  Once concerns are raised in the public record, the agency cannot claim ignorance. Ignoring well-supported comments increases the risk that a rule will be overturned for being arbitrary, unsupported by evidence, or contrary to law.

What is commenting?

Under the federal rulemaking process, an agency generally begins by publishing a proposed rule and opening a public comment period. During this time, members of the public may submit feedback, which the agency is required to review and take into account before issuing a final rule. Once finalized, the rule carries the force of federal law. Additional details about this process are available in this guide.

Are there risks to commenting?

Before submitting a public comment, individuals and organizations should thoughtfully evaluate their personal and professional risk. Public comments play an important role in advocacy efforts and can be valuable in future legal challenges, but participation should only occur if it feels safe to do so. Providing identifying information may carry risks, including the possibility that individuals or locations named in a comment could be subject to scrutiny.

Some commenters—such as transgender youth, family members, or providers of gender-affirming care—may face heightened vulnerability and should carefully consider whether to comment, what information to include, and if it should be submitted anonymously.

It is also important to note that all submitted comments are published on regulations.gov and are publicly accessible. Once a comment is submitted, it cannot be edited or withdrawn.

If you are submitting a comment as an individual, be mindful of the potential risks associated with sharing personal details such as your full name, home address, email, or phone number. You are not required to include identifying information and may choose to submit your comment anonymously. Any personal or medical information included in a comment will be visible both to the administration and to the public.

Individuals may also want to avoid sharing details that could make themselves or others identifiable, such as exact ages, locations, or the names of healthcare providers. For example, rather than describing specific circumstances that could point directly to you or a provider, you can speak more generally about your experience. Framing your comment around the broader impact of gender-affirming care—without unnecessary identifying details—can help reduce risk while still making your perspective clear.

We recommend:

Do anonymous comments matter?

Anonymous comments are permitted by the Administrative Procedure Act, the law governing the process of rulemaking. Like all comments, they become public and are posted online, but without your personal details. The Federal Register does not verify the identity of anonymous commenters.

Yes, anonymous comments can matter for the Federal Register and the rulemaking process, as agencies must consider all relevant, timely public input, but they are often weighed differently than identified comments, especially if they lack specific details. The quality of anonymous comments is essential for having the most impact.

To make your anonymous comment effective, do the following:

Explain Impacts: Clearly describe how a proposed rule will affect you, your community, or the public.

Avoid Identification: Be careful not to include details that could inadvertently identify you or others, like names, ages, provider information, specific locations like towns, occupations, schools…essentially anything that someone could use to identify you and your family.  

Be Specific: Provide facts, data, and detailed explanations, not just opinions.

Focus on the Rule: Concentrate on the substance of the regulation rather than personal identifiers. 

Tips for commenting

Focus on what you know and what you’ve lived. You are not expected to address every section of the proposal or respond to every argument it makes.

Write as much or as little as feels right to you. Effective comments don’t need to be long to be meaningful. Both the substance of comments and the number submitted play an important role in this process, so don’t let concerns about length prevent you from participating.

These prompts may be helpful as you think about what you want to share:

  • When you think about the future for yourself or your loved one, what role does access to health care play in helping that future feel possible?
  • How has gender-affirming care—or the lack of access to it—shaped your life or your family’s experience?
  • What obstacles to care have you already encountered, and how would additional restrictions affect you?
  • How would losing access to trusted providers or insurance coverage change your day-to-day life or well-being?

Formatting your comment

It is essential that your comment be unique. Please avoid using text pasted from a template; these comments are bundled together and largely ignored by the Federal Register.

The template below illustrates one way to structure your comment. It includes two separate address sections—one for each proposed rule—so you can use the appropriate block for the rule you are addressing. Text in italics should be replaced with your personal information, and bolded section headings can be customized or removed if you prefer to submit a shorter comment.

  1. Address Block for Rule on Hospital Participation in Medicare and Medicaid
    DATE, 2026
    Centers for Medicare and Medicaid Services
    U.S. Department of Health and Human Services
    Attention: CMS-3841-P

    Re: RIN 0938-AV87; CMS-3841-P
    Medicare and Medicaid Programs; Hospital Condition of Participation: Limiting Participation Based on the Performance of Sex Trait Modification Procedures on Children

    Dear Secretary Kennedy and Administrator Oz:

  2. Address Block for Rule on Medicaid/CHIP Funding Restrictions:
    DATE, 2026

    Centers for Medicare and Medicaid Services
    U.S. Department of Health and Human Services
    Attention: CMS-2451-P

    Re: RIN 0938-AV73; CMS-2451-P
    Medicaid Program; Prohibition on Federal Medicaid Funding for Sex Trait Modification Procedures Furnished to Children and Youth

    Dear Secretary Kennedy and Administrator Oz:

Suggested outline

Introduction:  state that you are submitting the comment in opposition to [insert federal rule] and are urging its withdrawal.

Your interest in the rule: a short paragraph detailing why this rule is important to you.

Opposition to the rule:  detail on your disagreement with the proposed rule. This could be whatever length necessary. We recommend using subheadings for longer comments. Examples of subheadings:
-Gender-affirming care for adolescents is safe and effective
-Restricting access to this care is harmful

Conclusion:  urge withdrawal of the proposed rule in its entirety. Include a closing and your name like you would on a business letter.

Examples of short public comments from previous rules

  • Anonymous comment submitted on the FTC’s request for information on gender-affirming care, August 27, 2025:
    I have worked in the field of mental health care with LGBTQ+ youth and adults for over 10 years. I am board-certified in my specialty and widely regarded as an expert in treated depression, anxiety, and distress in youth with traumatic experiences. I have treated hundreds of youth with gender distress along with many thoughtful, highly trained interdisciplinary doctors. We do not give preference to any particular outcome. The outcome that matters is helping youth live a safe, fulfilling life.
    The notion that youth are being overly pushed towards invasive, irreversible interventions to change their gender is not based in science. Care is widely individualized, trauma-informed, and staged thoughtfully. If there are isolated cases of doctors practicing against standards of care, there are disciplinary practices already in place by hospital and medical boards to address this. This is not a widespread issue at all; this is simply a talking point from people who do not understand, or do not care to understand, the breadth of human experience and the urgent need for freedom for families to make decisions with their doctors about care.
    Forbidding individualized care and removing parental consent is un-American. All parents have the right to make private, informed decisions with their medical providers.
  • Anonymous comment on the same rule, July 30, 2025:
    Gender-affirming care is not harmful, it is life-saving care. I am thankful for the positive effect it has had on my child. The decision to start this care is not taken lightly…it is a collaboration among parents, medical, and mental health professionals. The trans witch hunt in this country needs to stop. Just let people live their lives.

How to Submit Public Comments

Using Equality Connecticut’s secure portal:

Equality CT created a comment portal that individuals can use, providing a private, secure method for commenting. Comments will be submitted to the Federal Register by Equality CT.

Step 1: Open the secure comment portal

Step 2: Choose if you want to submit your comment(s) anonymously

Step 3: Enter contact information

Step 4: Select the rule(s) you wish to comment on:

Step 5: Enter the comment text in the box. Alternatively, you can upload a PDF or a Word document. If you are uploading, simply enter “See attached file” in the required text box.

Step 6: Ship it!

Ready to comment? Submit your comment(s) securely and privately through the portal

Using the Federal Register:

Step 1: Visit the rule’s page and click on the green button on the righthand side of the page:
Conditions of Participation rule
Medicaid and CHIP Funding rule

Step 2: Copy and paste your comment into the textbox or upload an attachment.

Step 3: Complete the following and submit.

Ask Others to Submit Public Comments

It is critical that the public submit a large volume of comments calling for the withdrawal of both rules. You can take the following actions to ensure that the register receives a strong wave of comments:

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