S3386-119

101. Exchange plan HSAs Section 223 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: For purposes of this section— In the case of an Exchange plan HSA, this section shall be applied as provided in paragraphs (3) through (4). The term Exchange plan HSA means a health savings account which is designated as an Exchange plan HSA upon the establishment of such account. Except in the case of a contribution from one Exchange plan HSA to another Exchange plan HSA, subsection (f)(5) shall not apply. For purposes of subsection (d)(2)(A), amounts paid for— abortion, other than— if the pregnancy is the result of an act of rape or incest, or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, or any sex trait modification procedure or service (as defined in section 156.400 of title 45, Code of Federal Regulations, as in effect on the date of the enactment of this subsection), Paragraph (4) of section 223(b) of the Internal Revenue Code of 1986 is amended by striking and at the end of subparagraph (B), by striking the period at the end of subparagraph (C) and inserting , and, and by inserting after subparagraph (C) the following new subparagraph: the aggregate amount contributed to an Exchange plan HSA pursuant to section 102(a) of the Health Care Freedom for Patients Act of 2025 which is excludable from the taxpayer's gross income for the taxable year under section 102(f) of such Act (and such amount shall not be allowed as a deduction under subsection (a)). The amendments made by this section shall apply to taxable years beginning after December 31, 2025. (i)Exchange plan HSAsFor purposes of this section—(1)In generalIn the case of an Exchange plan HSA, this section shall be applied as provided in paragraphs (3) through (4).(2)Exchange plan HSAThe term Exchange plan HSA means a health savings account which is designated as an Exchange plan HSA upon the establishment of such account.(3)No rollovers permittedExcept in the case of a contribution from one Exchange plan HSA to another Exchange plan HSA, subsection (f)(5) shall not apply.(4)Restriction on use of amountsFor purposes of subsection (d)(2)(A), amounts paid for—(A)abortion, other than—(i)if the pregnancy is the result of an act of rape or incest, or(ii)in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, or(B)any sex trait modification procedure or service (as defined in section 156.400 of title 45, Code of Federal Regulations, as in effect on the date of the enactment of this subsection),shall not be treated as paid for medical care.. (D)the aggregate amount contributed to an Exchange plan HSA pursuant to section 102(a) of the Health Care Freedom for Patients Act of 2025 which is excludable from the taxpayer's gross income for the taxable year under section 102(f) of such Act (and such amount shall not be allowed as a deduction under subsection (a))..

102. Exchange plan HSA contribution program As soon as administratively feasible, the Secretary of Health and Human Services shall make payments to the Exchange plan HSA of each individual who is an eligible enrollee, for each month which is an eligible month with respect to such individual, in the amount described in subsection (c). For purposes of this section, the term eligible month with respect to an individual means a calendar month— occurring in calendar year 2026 or 2027, and for which the individual is enrolled in a bronze level qualified health plan or a catastrophic plan through an Exchange established under subtitle D of title I of the Patient Protection and Affordable Care Act (42 U.S.C. 18021 et seq.). The amount of each payment under subsection (a) for any individual for an eligible month is 1/12 of— $1,000, in the case of an eligible enrollee who has attained age 18, and has not attained age 50, as of the first day of the calendar year which includes such month, and $1,500, in the case of an eligible enrollee who has attained age 50, and has not attained age 65, as of the first day of such calendar year. For purposes of this section, with respect to months occurring during a calendar year, the term eligible enrollee means an eligible individual (as defined in section 223(c)(1) of the Internal Revenue Code of 1986)— who has attained age 18, and has not attained age 65, as of the first day of such calendar year, in the case of an alien, who is an eligible alien, as defined in section 36B(e)(2)(B) of such Code (as in effect for taxable years beginning after December 31, 2026, applied by substituting for which the payment under section 102(a) of the Health Care Freedom for Patients Act of 2025 is made for for which the credit under this section is being claimed), and whose household income, expressed as a percent of the poverty line for the family size involved, does not exceed 700 percent. Upon election pursuant to paragraph (2) by an individual enrolling in a plan described in subsection (b)(2), the Secretary of Health and Human Services shall make a determination of the individual's status as an eligible enrollee on the basis of the latest determination pursuant to section 1412 of the Patient Protection and Affordable Care Act (42 U.S.C. 18082) of the individual's eligibility for the advance payment of the premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402 of such Act (42 U.S.C. 18071). At such time and in such manner as the Secretary of Health and Human Services shall provide, an eligible enrollee shall notify the Secretary of such enrollee's election to receive the payments under subsection (a) and shall provide— the social security number of such eligible enrollee, in the case of an alien, an attestation that the individual is an eligible alien, and sufficient information to allow for the identification of, and deposit of the payments under subsection (a) into, the Exchange plan HSA of the eligible enrollee. The Exchange through which an individual is enrolling in a plan described in subsection (b)(2) shall provide to the Secretary of Health and Human Services the information provided by the individual which is necessary for the determination under paragraph (1). The payments under subsection (a) with respect to any eligible months occurring before the determination under paragraph (1) is completed shall be made as early as possible after the completion of such determination. For purposes of the Internal Revenue Code of 1986, payments under subsection (a) shall not be included in gross income of an eligible enrollee. For purposes of this section— The term Exchange plan HSA has the meaning given such term in section 223(i) of the Internal Revenue Code of 1986. The terms household income, poverty line, and family size have the same respective meanings and shall be determined in the same manner as for purposes of section 36B of the Internal Revenue Code of 1986. The term bronze level qualified health plan means a qualified health plan, as defined in section 1301(a) of the Patient Protection and Affordable Care Act (42 U.S.C. 18021(a)), in the bronze level, as defined in section 1302(d)(1)(A) of such Act (42 U.S.C. 18022(d)(1)(A)). The term catastrophic plan means a plan described in section 1302(e) of such Act (42 U.S.C. 18022(e)). The Secretary of Health and Human Services shall prescribe such regulations or other guidance as are necessary to carry out the purposes of this section. In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $10,000,000,000 for each of fiscal years 2026 and 2027, to remain available until September 30, 2028, to carry out the purposes of this section. Paragraph (21) of section 6103(l) of the Internal Revenue Code of 1986 is amended— by striking or a basic health program under section 1331 of Patient Protection and Affordable Care Act in subparagraph (A) and inserting a basic health program under section 1331 of the Patient Protection and Affordable Care Act, or a payment under section 102(a) of the Health Care Freedom for Patients Act of 2025, by inserting , program, or payment after (and the amount thereof) in subparagraph (A)(v), and by striking State programs in subparagraph (C)(ii) and inserting State programs or payment.

103. Funding cost-sharing reduction payments Section 1402 of the Patient Protection and Affordable Care Act (42 U.S.C. 18071) is amended by adding at the end the following: There are appropriated, out of any monies in the Treasury not otherwise appropriated, such sums as may be necessary for purposes of making payments under this section for plan years beginning on or after January 1, 2027. The amounts appropriated under paragraph (1) may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion. Subparagraph (A) shall not apply to payments for a qualified health plan that provides coverage of abortion only if necessary to save the life of the mother or if the pregnancy is a result of an act of rape or incest. (h)Funding(1)In generalThere are appropriated, out of any monies in the Treasury not otherwise appropriated, such sums as may be necessary for purposes of making payments under this section for plan years beginning on or after January 1, 2027.(2)Use of funds(A)In generalThe amounts appropriated under paragraph (1) may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion.(B)ExceptionSubparagraph (A) shall not apply to payments for a qualified health plan that provides coverage of abortion only if necessary to save the life of the mother or if the pregnancy is a result of an act of rape or incest..

201. Expansion FMAP for certain States providing payments for health care furnished to certain individuals Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended— in subsection (y)— in paragraph (1)(E), by inserting (or, for calendar quarters beginning on or after October 1, 2027, in the case such State is a specified State with respect to such calendar quarter, 80 percent) after thereafter; and in paragraph (2), by adding at the end the following new subparagraph: The term specified State means, with respect to a quarter, a State that— provides any form of financial assistance from a State general fund during such quarter, in whole or in part, whether or not made under a State plan (or waiver of such plan) under this title or under another program established by the State, to or on behalf of an alien who is not a qualified alien and is not a child or pregnant woman who is lawfully residing in the United States and eligible for medical assistance pursuant to section 1903(v)(4) or for child health assistance or pregnancy-related assistance pursuant to section 2107(e)(1)(Q), for the purchasing of health insurance coverage (as defined in section 2791(b)(1) of the Public Health Service Act) for an alien who is not a qualified alien and is not such a child or pregnant woman; or provides any form of comprehensive health benefits coverage, except such coverage required by Federal law, during such quarter, whether or not under a State plan (or waiver of such plan) under this title or under another program established by the State, and regardless of the source of funding for such coverage, to an alien who is not a qualified alien and is not such a child or pregnant woman. The term alien has the meaning given such term in section 101(a) of the Immigration and Nationality Act. The term qualified alien has the meaning given such term in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, except that the references to (in the opinion of the agency providing such benefits) in subsection (c) of such section 431 shall be treated as references to (in the opinion of the State in which such comprehensive health benefits coverage or such financial assistance is provided, as applicable). in subsection (z)(2)— in subparagraph (A), by striking for such year and inserting for such quarter; and in subparagraph (B)(i)— in the matter preceding subclause (I), by striking for a year and inserting for a calendar quarter in a year; and in subclause (II), by striking for the year and inserting for the quarter for the State. (C)Specified StateThe term specified State means, with respect to a quarter, a State that—(i)provides any form of financial assistance from a State general fund during such quarter, in whole or in part, whether or not made under a State plan (or waiver of such plan) under this title or under another program established by the State, to or on behalf of an alien who is not a qualified alien and is not a child or pregnant woman who is lawfully residing in the United States and eligible for medical assistance pursuant to section 1903(v)(4) or for child health assistance or pregnancy-related assistance pursuant to section 2107(e)(1)(Q), for the purchasing of health insurance coverage (as defined in section 2791(b)(1) of the Public Health Service Act) for an alien who is not a qualified alien and is not such a child or pregnant woman; or(ii)provides any form of comprehensive health benefits coverage, except such coverage required by Federal law, during such quarter, whether or not under a State plan (or waiver of such plan) under this title or under another program established by the State, and regardless of the source of funding for such coverage, to an alien who is not a qualified alien and is not such a child or pregnant woman.(D)Immigration terms(i)AlienThe term alien has the meaning given such term in section 101(a) of the Immigration and Nationality Act.(ii)Qualified alienThe term qualified alien has the meaning given such term in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, except that the references to (in the opinion of the agency providing such benefits) in subsection (c) of such section 431 shall be treated as references to (in the opinion of the State in which such comprehensive health benefits coverage or such financial assistance is provided, as applicable). ; and

202. Prohibiting Federal financial participation under Medicaid and CHIP for individuals without verified citizenship, nationality, or satisfactory immigration status Section 1903(i)(22) of the Social Security Act (42 U.S.C. 1396b(i)(22)) is amended— by adding and at the end; by striking to amounts and inserting "to— amounts by adding at the end the following new subparagraph: in the case that the State elects under section 1902(a)(46)(C) to provide for making medical assistance available to an individual during— the period in which the individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under section 1902(ee)(2)(C) or subsection (x)(4); the 90-day period described in section 1902(ee)(1)(B)(ii)(II); or the period in which the individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4), Section 2107(e)(1)(O) of the Social Security Act (42 U.S.C. 1397gg(e)(1)(O)) is amended by striking and (17) and inserting (17), and (22). Section 1903(x)(4) of the Social Security Act (42 U.S.C. 1396b(x)) is amended— by striking under clauses (i) and (ii) of section 1137(d)(4)(A) and inserting under section 1137(d)(4); and by inserting , except that the State shall not be required to make medical assistance available to such individual during the period in which such individual is provided such reasonable opportunity if the State has not elected the option under section 1902(a)(46)(C) before the period at the end. Section 1902(ee) of the Social Security Act (42 U.S.C. 1396a(ee)) is amended— in paragraph (1)(B)(ii)— in subclause (II), by striking (and continues to provide the individual with medical assistance during such 90-day period) and inserting and, if the State has elected the option under subsection (a)(46)(C), continues to provide the individual with medical assistance during such 90-day period; and in subclause (III), by inserting , or denies eligibility for medical assistance under this title for such individual, as applicable after under this title; and in paragraph (2)(C)— by striking under clauses (i) and (ii) of section 1137(d)(4)(A) and inserting under section 1137(d)(4); and by inserting , except that the State shall not be required to make medical assistance available to such individual during the period in which such individual is provided such reasonable opportunity if the State has not elected the option under section 1902(a)(46)(C) before the period at the end. Section 1137(d)(4) of the Social Security Act (42 U.S.C. 1320b–7(d)(4)) is amended— in subparagraph (A)(ii), by inserting (except that such prohibition on delay, denial, reduction, or termination of eligibility for benefits under the Medicaid program under title XIX shall apply only if the State has elected the option under section 1902(a)(46)(C)) after has been provided; and in subparagraph (B)(ii), by inserting (except that such prohibition on delay, denial, reduction, or termination of eligibility for benefits under the Medicaid program under title XIX shall apply only if the State has elected the option under section 1902(a)(46)(C)) after status. Section 1902(a)(46) of the Social Security Act (42 U.S.C. 1396a(a)(46)) is amended— in subparagraph (A), by striking and at the end; in subparagraph (B)(ii), by adding and at the end; and by inserting after subparagraph (B)(ii) the following new subparagraph: provide, at the option of the State, for making medical assistance available— to an individual described in subparagraph (B) during the period in which such individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under subsection (ee)(2)(C) or section 1903(x)(4), or during the 90-day period described in subsection (ee)(1)(B)(ii)(II); or to an individual who is not a citizen or national of the United States during the period in which such individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4); Section 2105(c)(9) of the Social Security Act (42 U.S.C. 1397ee(c)(9)) is amended by adding at the end the following new subparagraph: Section 1902(a)(46)(C) shall apply to States under this title in the same manner as it applies to a State under title XIX. The amendments made by this section shall apply beginning on October 1, 2026. (A)amounts; and (B)in the case that the State elects under section 1902(a)(46)(C) to provide for making medical assistance available to an individual during—(i)the period in which the individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under section 1902(ee)(2)(C) or subsection (x)(4);(ii)the 90-day period described in section 1902(ee)(1)(B)(ii)(II); or(iii)the period in which the individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4),amounts expended for such medical assistance, unless the citizenship or nationality of such individual or the satisfactory immigration status of such individual (as applicable) is verified by the end of such period;. (C)provide, at the option of the State, for making medical assistance available—(i)to an individual described in subparagraph (B) during the period in which such individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under subsection (ee)(2)(C) or section 1903(x)(4), or during the 90-day period described in subsection (ee)(1)(B)(ii)(II); or(ii)to an individual who is not a citizen or national of the United States during the period in which such individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4);. (C)Option to continue providing child health assistance during reasonable opportunity periodSection 1902(a)(46)(C) shall apply to States under this title in the same manner as it applies to a State under title XIX..

301. Prohibiting coverage of gender transition procedures as an essential health benefit under plans offered by Exchanges Section 1302(b)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(b)(2)) is amended by adding at the end the following new subparagraph: For plan years beginning on or after January 1, 2027, the essential health benefits defined pursuant to paragraph (1) may not include items and services furnished for a gender transition procedure. Section 1304 of the Patient Protection and Affordable Care Act (42 U.S.C. 18024) is amended by adding at the end the following new subsection: In this title, except as provided in paragraph (2), the term gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: Performing any surgery, including— castration; sterilization; orchiectomy; scrotoplasty; vasectomy; tubal ligation; hysterectomy; oophorectomy; ovariectomy; metoidioplasty; clitoroplasty; reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; penectomy; phalloplasty; vaginoplasty; vaginectomy; vulvoplasty; reduction thyrochondroplasty; chondrolaryngoplasty; mastectomy; and any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual. Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis. Any placement of fat or artificial implants in the gluteal region. Administering, prescribing, or dispensing to an individual medications, including— gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex. Paragraph (1) shall not apply to the following: Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty. Medically necessary procedures or treatments to correct for— a medically verifiable disorder of sex development, including— 46,XX chromosomes with virilization; 46,XY chromosomes with undervirilization; and both ovarian and testicular tissue; sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing; infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation. For purposes of this subsection, the term sex means either male or female, as biologically determined and defined by subparagraph (A) and subparagraph (B). The term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. The term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. (C)Gender transition proceduresFor plan years beginning on or after January 1, 2027, the essential health benefits defined pursuant to paragraph (1) may not include items and services furnished for a gender transition procedure.. (f)Gender transition procedure(1)In generalIn this title, except as provided in paragraph (2), the term gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex:(A)Performing any surgery, including—(i)castration;(ii)sterilization;(iii)orchiectomy;(iv)scrotoplasty;(v)vasectomy;(vi)tubal ligation;(vii)hysterectomy;(viii)oophorectomy;(ix)ovariectomy;(x)metoidioplasty;(xi)clitoroplasty;(xii)reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty;(xiii)penectomy;(xiv)phalloplasty;(xv)vaginoplasty;(xvi)vaginectomy;(xvii)vulvoplasty;(xviii)reduction thyrochondroplasty;(xix)chondrolaryngoplasty;(xx)mastectomy; and(xxi)any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual.(B)Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis.(C)Any placement of fat or artificial implants in the gluteal region.(D)Administering, prescribing, or dispensing to an individual medications, including—(i)gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and(ii)testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex.(2)ExceptionParagraph (1) shall not apply to the following:(A)Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty.(B)Medically necessary procedures or treatments to correct for—(i)a medically verifiable disorder of sex development, including—(I)46,XX chromosomes with virilization;(II)46,XY chromosomes with undervirilization; and(III)both ovarian and testicular tissue;(ii)sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing;(iii)infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or(iv)procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation.(3)SexFor purposes of this subsection, the term sex means either male or female, as biologically determined and defined by subparagraph (A) and subparagraph (B).(A)FemaleThe term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization.(B)MaleThe term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization..

302. Prohibiting Federal Medicaid and CHIP funding for certain items and services Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) is amended— in paragraph (26), by striking ; or and inserting a semicolon; in paragraph (27), by striking the period at the end and inserting ; or; by inserting after paragraph (27) the following new paragraph: with respect to any amount expended for specified gender transition procedures (as defined in section 1905(ll)) furnished to an individual enrolled in a State plan (or waiver of such plan). in the flush left matter at the end, by striking and (18), and inserting (18), and (28). Section 2107(e)(1)(O) of the Social Security Act (42 U.S.C. 1397gg(e)(1)(O)), as amended by this Act, is further amended by striking and (22) and inserting (22), and (28). Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection: For purposes of section 1903(i)(28), except as provided in paragraph (2) , the term specified gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: Performing any surgery, including— castration; sterilization; orchiectomy; scrotoplasty; vasectomy; tubal ligation; hysterectomy; oophorectomy; ovariectomy; metoidioplasty; clitoroplasty; reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; penectomy; phalloplasty; vaginoplasty; vaginectomy; vulvoplasty; reduction thyrochondroplasty; chondrolaryngoplasty; mastectomy; and any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual. Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis. Any placement of fat or artificial implants in the gluteal region. Administering, prescribing, or dispensing to an individual medications, including— gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex. Paragraph (1) shall not apply to the following when furnished to an individual by a health care provider if the individual is a minor with the consent of such individual’s parent or legal guardian: Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty. Medically necessary procedures or treatments to correct for— a medically verifiable disorder of sex development, including— 46,XX chromosomes with virilization; 46,XY chromosomes with undervirilization; and both ovarian and testicular tissue; sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing; infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation. For purposes of paragraph (1), the term sex means either male or female, as biologically determined and defined in paragraphs (4) and (5), respectively. For purposes of paragraph (3), the term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. For purposes of paragraph (3), the term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. (28)with respect to any amount expended for specified gender transition procedures (as defined in section 1905(ll)) furnished to an individual enrolled in a State plan (or waiver of such plan).; and (ll)Specified gender transition procedures(1)In generalFor purposes of section 1903(i)(28), except as provided in paragraph (2) , the term specified gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: (A)Performing any surgery, including—(i)castration;(ii)sterilization;(iii)orchiectomy;(iv)scrotoplasty;(v)vasectomy;(vi)tubal ligation;(vii)hysterectomy;(viii)oophorectomy;(ix)ovariectomy;(x)metoidioplasty;(xi)clitoroplasty;(xii)reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty;(xiii)penectomy;(xiv)phalloplasty;(xv)vaginoplasty;(xvi)vaginectomy;(xvii)vulvoplasty;(xviii)reduction thyrochondroplasty;(xix)chondrolaryngoplasty;(xx)mastectomy; and(xxi)any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual.(B)Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis.(C)Any placement of fat or artificial implants in the gluteal region.(D)Administering, prescribing, or dispensing to an individual medications, including—(i)gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and(ii)testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex.(2)ExceptionParagraph (1) shall not apply to the following when furnished to an individual by a health care provider if the individual is a minor with the consent of such individual’s parent or legal guardian:(A)Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty.(B)Medically necessary procedures or treatments to correct for—(i)a medically verifiable disorder of sex development, including—(I)46,XX chromosomes with virilization;(II)46,XY chromosomes with undervirilization; and(III)both ovarian and testicular tissue;(ii)sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing;(iii)infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or(iv)procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation.(3)SexFor purposes of paragraph (1), the term sex means either male or female, as biologically determined and defined in paragraphs (4) and (5), respectively.(4)FemaleFor purposes of paragraph (3), the term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization.(5)MaleFor purposes of paragraph (3), the term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization..