MaineCare Coverage of Gender-Affirming Care for Medicaid Beneficiaries Under Age 18 and Children's Health Insurance Program (CHIP) Enrollees Under Age 19

Oct 09, 2026

As described in the message sent September 18, 2026, the Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register on August 13, 2026, that limits federal Medicaid and CHIP funding for certain gender-affirming care provided to minors. This rule prohibits federal matching funds for puberty blockers, cross-sex hormone therapy, and surgical interventions when used for gender transition for Medicaid beneficiaries under age 18 and CHIP enrollees under age 19. The federal rule is scheduled to take effect on October 13, 2026. 

The federal rule does not prohibit states from using state-only funds to cover these services. Maine law requires MaineCare to cover medically necessary treatment for or related to gender dysphoria and protects members from discrimination based on gender identity or gender expression.   

To ensure we are in compliance with this new federal rule, we have established the billing requirements below for providers who deliver gender-affirming care services to Medicaid beneficiaries under age 18 and CHIP enrollees under age 19. 

Effective on October 13, 2026, medical claims submitted through the MIHMS system must: 

• Include applicable gender-affirming care diagnosis codes on all claims. 
• Include the SE modifier on any claims submitted for gender-affirming care, other than behavioral health services.  
  • The SE modifier is used to identify a service that must be reimbursed using state-only funds.  
  • The SE modifier should be listed after any other modifiers on the applicable claim line(s). 
  • Behavioral health treatment for gender dysphoria is still eligible for federal match, so providers are not required to include the SE modifier on behavioral health-related claims.  

Effective on October 9, 2026, pharmacy claims submitted through the MEPOPS system must:  

• Have Prior Authorization (PA) as required on the Department’s Preferred Drug List. This requirement applies to preferred and non-preferred products on the Department’s identified medication list.   
• Include the medication’s intended clinical use by including the applicable diagnosis code and the information needed to determine the appropriate coverage and funding pathway.  
  • Medication prescribed for a clinical use outside the scope of 42 CFR § 441.801–441.802 and 457.476 remains subject to the otherwise applicable MaineCare pharmacy criteria. For medication prescribed for use within the scope of those provisions, the Department will review coverage under its separately funded state-only benefit.  

This PA requirement is used to determine clinical purpose and payment source. It does not, by itself, change the drug’s preferred status, establish additional step therapy, or mean that all uses of the medication are excluded from federally matched coverage. Existing drug-specific clinical criteria continue to apply as appropriate.  

For questions, please contact Provider Relations Specialist, Lisa Bouchard.