Navigating Gender-Affirming Care and Supportive Services in 2026

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Milo Vieland (he/him), Trans Health Law Program Coordinator, LCHJ

Rory Peters (they/them), Staff Attorney, LCHJ

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Healthcare Access:

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Healthcare rights, youth care bans, and private and public insurance coverage.

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Components of Transition-Related Healthcare Access

• Federal restrictions - criminalization of care
• Federal restrictions - federal funding
• State protections

• Public insurance - Medicaid & Medicare
• Private insurance - ACA & employer-based plans
• Insurance company corporate policies
• State insurance regulation
• Consumer appeal rights

Legal Landscape

Payment & Insurance Coverage

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Legal Context

• Illinois Human Rights Act
• Shield Law
• Illinois Insurance Code

January 2025 - EO 14168: Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government

January 2025 - EO 14187: Protecting Children from Chemical and Surgical Mutilation

April 2025 HHS release of Review of Evidence and Best Practices for Gender-Affirming Care

April 2025 - White House Fact Sheet: Report to the President on Protecting Children from Surgical and Chemical Mutilation Executive Summary

April 2025 - DOJ Memo Preventing the Mutilation of American Children

June 2025: Skrmetti decision; Supreme Court upholds Tennessee ban on gender affirming care for minors

June 2025 - HHS Final Rule: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability

December 2025 - Kennedy Declaration Re: Safety, Effectiveness, and Professional Standards of Care for Sex-Rejecting Procedures on Children and Adolescents

December 2025 - HHS Proposed Rule: Medicare and Medicaid Programs; Hospital Conditions of Participation: Prohibiting Sex-Rejecting Procedures for Children

December 2025 - HHS Proposed Rule: Medicaid Program; Prohibition on Federal Medicaid and Children’s Health Insurance Program Funding for Sex-Rejecting Procedures Furnished to Children

December 2025 - HHS Proposed Rule: Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance

January 2026 - State Department Final Rule: Combating Gender Ideology in Foreign Assistance

January 2026 - HHS referral of six hospitals (including Lurie) to OIG for investigation

January 2026 - OCR Notice of Violation to Illinois Governor, Attorney General, and Secretary of IDFPR regarding Illinois Health Care Right of Conscience Act

February 2026 - American Society of Plastic Surgeons Position Statement on Gender Surgery for Children and Adolescents

March 2026 - On remand following the Skrmetti decision, 4th Circuit Court of Appeals rules that West Virginia’s ban on Medicaid coverage of “sex change surgeries” does not violate the Equal Protection Clause or Affordable Care Act

• Title VII
• Section 504
• ACA Section 1557
• 7th Circuit precedent
• ERISA
• Bostock v. Clayton County
• U.S. v. Skrmetti

State law:

Federal law:

Federal actions:

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Legal Protections in Illinois

Illinois Human Rights Act (IHRA)

• Prohibits employment discrimination on the basis of gender identity
• Includes protections against health plan coverage exclusions
• Prohibits discrimination in public accommodations
• Includes healthcare protections against refusal to admit or treat patients, refusal to offer hormone treatment for transition-related care when offered for other purposes, discriminatory room assignments or restroom access, harassment

Shield Law

• Protection from out-of-state investigations and prosecutions
• State agencies/employees barred from assisting out-of-state entities
• Governor may not surrender someone charged in another state
• Privacy Protections
• Gender affirming care (“lawful healthcare”) records are confidential and exempt under FOIA
• Automatic license plate readers may not share info with out-of-state law enforcement

Illinois Insurance Code

• Prohibits categorical exclusions of medically necessary services for the treatment of gender dysphoria
• Requires use of valid, evidence-based sources reflecting current generally accepted standards of care, including recommendations of nonprofit health care provider professional associations and speciality socieites

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Payment & Coverage: Private Insurance in Illinois

1. Pre-authorization
• Limited provider network (especially for managed care)
• Medical necessity letters
• Medical necessity review based on company clinical policy guidelines
2. One to two internal appeals
• Internal company review based on company clinical policy guidelines
3. External independent review
• Companies contracted with IDOI to provide external review services
• Binding and final (“except to the extent the covered person has other remedies available under applicable federal or State law”)

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Payment & Coverage: Illinois Medicaid

89 Ill. Adm. Code 140.413

A) Prior approval requirement for GAC surgeries/services for individuals 21 and older; list of requirements for establishing medical necesity.

B) “The Department will cover all gender-affirming surgeries, services and procedures that are medically necessary to treat a particular individual’s gender dysphoria and are listed on the Department’s fee schedule and in the Practitioner handbook.”

E) “…payment for gender-affirming surgeries, services and procedures for patients under 21 years of age will be made in specific cases if medical necessity is demonstrated and prior approval is received.”

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89 Ill. Adm. Code 140.440

“The department will cover hormone therapy, whether or not in preparation for gender-affirming surgery…”

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Payment & Coverage: Illinois Medicaid

1. Pre-authorization
1. Very limited provider networks; geographic limitations
2. Long wait lists
3. Medical necessity letters
4. Technical issues with e.g., electrolysis

(2) Internal appeal (MCO)

• Private company clinical policies utilized in e.g., pharmacy benefits

(3) Administrative appeal (State Fair Hearing)

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Components of Transition-Related Healthcare Access: Takeaways

• IL law protections are strong, but enforcement can be challenging
• Federal law does not currently ban GAC for any age group, but we have a long road ahead
• Funding is key
• Federal actions have a chilling effect, and enable repressive states

• ACA and Medicaid coverage in IL should be straightforward
• Employer plans may pose unique challenges
• Individuals with public and private insurance have appeal rights - use them!
• Call IL Pride Connect for support with any coverage or billing issues

Legal Landscape

Payment & Insurance Coverage

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Student Rights & School Supports:

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The national landscape is shifting constantly, but for now, Illinois law is still good law

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Common Issues Faced by TGNC Students

• Bullying and harassment
• Lack of privacy/confidentiality
• Noncompliance with gender support plans

• Gender-segregated facilities
• Gender-segregated activities
• Special requirements/restrictions

Unsafe environment

Unequal access/participation

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Legal Context

• Illinois Human Rights Act
• Illinois School Code
• Non-binding guidance from IDHR and ISBE

Jan 20, 2025 – EO 14168: Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government

Jan 29, 2025 – EO 14190: Ending Radical Indoctrination in K-12 Schooling

Feb 5, 2025 – EO 14201: Keeping Men Out of Women’s Sports

Feb 6, 2025 – OCR launches first investigations over school athletics policies

Apr 4, 2025 – ED and DOJ announce new Title IX Special Investigations Team “to protect students, and especially female athletes, from the pernicious effects of gender ideology”

Feb thru Dec – ED continues investigating K-12 school districts, universities, state departments of ed, and athletic associations for Title IX and FERPA violations

Dec 19, 2025 – HHS proposes rule that would exclude gender dysphoria from Section 504’s definition of disability

Jan 14, 2026 – OCR launches 18 new Title IX investigations

Jan 28, 2026 – ED finds that CA Dep’t of Ed violated FERPA by “concealing info about students’ gender identity” and using “secret” gender support plans

• Title IX
• Section 504
• FERPA
• 7th Circuit precedent

• West Virginia v. BPJ
• Little v. Hecox
• January Littlejohn v. Sch. Bd. Of Leon Cnty., Fla. (pending cert)

State law:

Federal law:

Pending SCOTUS decisions:

Federal actions:

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Protections in Illinois

1. Students have the right to be addressed at school by their chosen name and pronouns, and to update most of their school records to reflect their identity
2. Students must be allowed to fully and equally access gendered facilities and activities that align with their gender identity
3. Any dress codes based on gender differences must permit students to dress in a manner that corresponds with their gender identity
4. Students have the right to be free from bullying and harassment on the basis of gender-related identity or expression

Students have these rights regardless of parental involvement/consent

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Enforcement Mechanisms

1. Informal negotiations with the school through meetings and/or a demand letter (can be more challenging if no attorney/advocate involved)
2. IDHR complaint and investigation → appeal to Illinois Human Rights Commission (very slow, public record)
3. State court (high risk of student privacy and safety issues, public record)

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With so few ways of enforcing students’ legal rights, what else can service providers do to support trans youth?

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Gender Support Plans

• Intended to create a shared understanding about how a student’s gender identity will be accounted for and supported at school
• May address names, pronouns, gendered facilities and activities, privacy concerns, safety plans, and other areas where a student’s gender identity may be implicated
• Creation/use of GSPs does not need to involve parents,** but schools generally must disclose them if parents request student records under ISSRA/FERPA

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Other School Supports

School districts can further support TGNC students through…

• Regular staff trainings
• Easily accessible info about rights
• Staff accountability
• Gender Support Model and Gender Support Coordinators
• Annual GSP meetings
• Safety transfers

Other service providers can support TGNC students through…

• Regular staff trainings
• Easily accessible info about rights
• Staff accountability
• Awareness of other risk factors
• Action plans
• Legal referrals
• What other supports can you or your organization provide?

legalcouncil.org

Milo Vieland - mvieland@legalcouncil.org

Rory Peters - rpeters@legalcouncil.org

legalcouncil.org