DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland  21244-1850 
 
 
CMCS Informational Bulletin 
 
DATE:  November 9, 2023 
 
FROM:  Daniel Tsai, Deputy Administrator & Director 
Center for Medicaid and CHIP Services 
 
SUBJECT:  Guidance on Adding Sexual Orientation and Gender Identity Questions to State 
Medicaid and CHIP Applications for Health Coverage 
 
 
Starting November 1, 2023, the Centers for Medicare & Medicaid Service (CMS) began asking 
three new optional sexual orientation and gender identity (SOGI) questions on the single, 
streamlined application developed by the Secretary in accordance with 42 CFR 435.907(b)(1) and 
457.330 (model application).1 The model application is used by the Marketplaces that use the 
Federal eligibility and enrollment platform. The purpose of the SOGI questions is to enhance 
consumer experience by allowing consumers to attest in a way that better reflects and affirms their 
identities, improve demographic data collection to identify disparities in access to care and, 
ultimately, to support appropriate and equitable health care. These three new optional questions 
will complement the existing sex question, which will continue to be required (see Table 1).  
 
States are not required to add the SOGI questions to their Medicaid and Childrens Health 
Insurance Program (CHIP) applications but have the option to do so consistent with this guidance. 
The model application is used by states to guide the development of their Medicaid and CHIP 
applications. Going forward, State Medicaid and CHIP agencies seeking to ask SOGI questions 
may add the questions to the model application or an alternative application approved by CMS.2 
These may include a states alternative single, streamlined application, multi-benefit application 
that includes health coverage, applications or supplemental forms used for determining eligibility 
on a basis other than Modified Adjusted Gross Income (MAGI), or any other alternative 
applications used in the state. 
 
For states that wish to incorporate these questions into their applications, this Center for Medicaid 
& CHIP Services (CMCS) Informational Bulletin (CIB) provides guidance on the processes states 
should follow to modify their applications and when states may be required to submit for CMS 
approval changes made to add SOGI questions to a states alternative single, streamlined 
application. This CIB also addresses the safeguards that states must put in place to protect the 
privacy and security of beneficiary data, including any SOGI data they collect. Finally, this CIB 
provides an update on the CMS collection of SOGI data as part of future Transformed Medicaid 
Statistical Information System (T-MSIS) data submissions.  
 
 
1 Please refer to https://www.cms.gov/files/document/sogi-questions-marketplace-application.pdf for more information.  
2 42 CFR 435.907(b) and 457.330.   
 
OVERVIEW OF MODEL APPLICATION SOGI QUESTIONS AND RESPONSES  
 
Prior to the introduction of the SOGI questions, the model application required each individual in 
the household, regardless of age, to respond to a single binary Sex question. This question 
required a Male or Female response. No non-binary response options, nor a distinction 
between gender identity and sex assigned at birth, were available for selection. Additionally, 
individuals who responded Female were subsequently asked and required to provide their 
pregnancy status.  
 
The Sex question on the model application will continue to be a required question on the model 
application, and only individuals who respond Female will continue to be asked whether they 
are pregnant.  
  
The new SOGI questions on the model application include two questions on gender identity (sex 
assigned at birth and current gender) and one question on sexual orientation. The SOGI questions 
are optional questions asked about applicants and all individuals in the household ages 12 or older 
for demographic data collection. Responses to the questions or failure to provide a response must 
not impact an individuals eligibility determination or be considered an incomplete application for 
the purposes of making a determination.  
 
Table 1: Sexual Orientation and Gender Identity Questions on the Model Application 
Question   Responses  
Sex   Male (does not trigger pregnancy question) 
(existing question, required, single select)    Female (triggers pregnancy question) 
 Female  
What was [First Name]s sex assigned at 
 Male  
birth? You can find this on an original birth 
 A sex thats not listed: [free text]  
certificate or similar document.  
 Not sure  
(new question, optional, single select)  
 Prefer not to answer  
 Female  
 Male  
 Transgender female  
Whats [First Name]s gender identity?  
 Transgender male  
(new question, optional, single select)  
 A gender identity thats not listed: [free text]  
 Not sure  
 Prefer not to answer  
 Lesbian or gay  
 Straight  
Whats [First Name]s sexual orientation?   Bisexual  
(new question, optional, single select)    A sexual orientation that is not listed: [free text]  
 Not sure  
 Prefer not to answer  
 
 
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BACKGROUND ON MEDICAID AND CHIP ALTERNATIVE APPLICATIONS 
 
Section 1413 of the Affordable Care Act establishes a streamlined enrollment system for all 
insurance affordability programs, including Medicaid, CHIP, and advanced payment of premium 
tax credit (APTC) for coverage through the Marketplaces. Under section 1413(b) of the 
Affordable Care Act, insurance affordability programs must use the single streamlined 
application form developed by the Secretary or an alternative, state developed form, as discussed 
more fully below. Sections 1943 and 2107 of the Social Security Act (the Act) requires state 
Medicaid and CHIP agencies to participate in and comply with the requirements for this 
streamlined enrollment system, including the streamlined application requirements.3  
 
As described in regulations at 42 CFR 435.907(b) and 457.330, the single, streamlined 
application must be either the model application, or an alternative developed by the state and 
approved by CMS through a state plan amendment (SPA). In addition to the single, streamlined 
application, many states have applications or supplemental forms for determining eligibility on a 
basis other than MAGI, or other alternative applications not subject to CMS approval. 
 
More detailed information on the development, review, and approval of alternative applications is 
available in the June 18, 2013, joint Center for Consumer Information and Insurance Oversight 
and Center for Medicaid and CHIP Services guidance entitled Guidance on State Alternative 
Applications for Health Coverage.4  
 
 
STATE OPTION TO ADD SOGI QUESTIONS TO MEDICAID AND CHIP 
APPLICATIONS 
 
Although not required, states have the opportunity to add optional SOGI questions to their 
Medicaid and CHIP applications. States that do not wish to include these SOGI questions may 
continue using their current applications without change. 
 
As discussed in more detail in the next section, states that wish to include the SOGI questions 
and response options to their alternative single, streamlined application exactly as they are 
worded on the model application (as noted above in Table 1) will not be required to seek CMS 
approval and will not need to submit Medicaid or CHIP SPAs. For states that wish to use 
alternative language approaches, Medicaid or CHIP SPAs will not be necessary for all 
approaches. States will need to work with CMS to determine if CMS approval and a SPA is 
needed (see additional information about modifications that may require CMS approval 
below).  
 
DESIGNING AND SUBMITTING SOGI QUESTIONS FOR ALTERNATIVE MEDICAID 
AND CHIP APPLICATIONS 
  
This section outlines the parameters for adding SOGI questions to the Medicaid and CHIP 
 
3 Section 1943(b)(3) of the Act; Section 2107(e)(1)(S) of the Act  
4 https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/state-alt-app-guidance-6-18-2013.pdf 
3 
 
   
alternative applications and discusses situations when CMS approval may or may not be 
necessary for the addition of SOGI questions to a states alternative single, streamlined 
application that are not identical to the SOGI questions on the model application. 
Modifications that Do Not Require CMS Approval 
 
There are several ways that a state may adapt the SOGI questions from the model application 
without approval from CMS. Examples of changes that would not require CMS approval or a 
SPA include: 
 
1.  Displaying the SOGI questions and response options exactly as they are worded in the model 
application (see Table 1, above). 
 
2.  Changing the placement and order of the SOGI questions from the model application, as 
long as the change does not impede the online applications dynamic nature. However, the 
state must collect age information prior to asking the SOGI questions to ensure that the 
SOGI questions are asked only about applicants and all household members ages 12 or 
older. 
 
3.  Making modifications to minimize consumer burden, such as having the SOGI questions 
from the model application appear after an applicant signs and submits an application or after 
the state has determined the individuals eligibility. 
 
Modifications that May Require CMS Approval 
 
States that seek to update their Medicaid or CHIP alternative applications to incorporate SOGI 
questions using alternative language or modified response options will need to work with CMS 
and may need CMS approval. For example, states that implement only one or two of the three 
SOGI questions or states that use alternative wording in the SOGI questions and/or response 
options will need to work with CMS to ensure that the states proposed SOGI questions are 
consistent with the applicable statute and regulations and minimize burden on applicants.  
 
Any alternative SOGI questions must be optional and may not be a barrier to completion and 
submission of an application or to an eligibility determination. States may not require applicants 
to answer the SOGI questions, even if there is a prefer not to answer response option.  
 
Process for Submission and Approval of Alternative Applications 
 
As discussed above, states that wish to add the SOGI questions as written from the model 
application do not need CMS approval and do not need to submit a Medicaid or CHIP SPA. 
However, states that seek to update their Medicaid or CHIP alternative, single streamlined 
applications to incorporate SOGI questions using alternative language or modified response 
options will need to work with CMS to determine whether CMS approval and a SPA is needed. 
Such states will need to provide a detailed description of the proposed questions to its paper and 
online applications, including information about the design and functionality of the online 
application, or submit design documents and/or online screenshots for CMS review. States that 
propose significant deviations from the model application may need to submit a SPA.  
 
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Whenever a state submits a SPA to make changes to its alternative single, streamlined application, 
CMS conducts a full review of the states application for compliance with federal requirements. 
Thus, if CMS determines that a SPA is needed to add SOGI questions that differ from the model 
application questions, the states amended application will be subject to a full application review. 
 
Regardless of whether a state needs to submit a SPA, states collecting this information using 
response options that differ from those included in the model application should be prepared to 
take any necessary steps to ensure their submissions to CMS accord with forthcoming T-MSIS 
technical specifications, which will align with the response options included in the model 
application. States should also acquaint themselves with recently issued guidance on collecting 
SOGI data on administrative forms.5 
 
 
CONFIDENTIALITY OF APPLICANT AND BENEFICIARY INFORMATION  
  
Section 1902(a)(7) of the Act and implementing regulations at 42 C.F.R. part 431, subpart F, 
require state Medicaid agencies to provide safeguards that restrict the use or disclosure of 
information concerning Medicaid applicants and beneficiaries to uses or disclosures that are 
directly connected with the administration of the Medicaid state plan. The same requirements 
also apply to separate CHIPs through a cross reference at 42 C.F.R.  457.1110(b).  
 
Purposes that are directly connected to the Medicaid and CHIP State plan administration 
include: establishing eligibility, determining the amount of medical or child health assistance, 
providing services for beneficiaries, and conducting or assisting an investigation, prosecution, or 
civil or criminal proceeding related to the administration of the plan under 42 C.F.R.  431.302 
for Medicaid and  457.1110(b) for CHIP. By contrast, state Medicaid or CHIP agency use or 
disclosure of applicants or beneficiaries SOGI or other data for a purpose not directly related to 
the administration of the state plan is prohibited under section 1902(a)(7) of the Act and 
regulations at 42 C.F.R. part 431, subpart F and 42 C.F.R.  457.1110(b). Examples of 
prohibited use or disclosure of applicants or beneficiaries SOGI or other data include to enable 
child welfare investigations or to pursue criminal charges or civil penalties that are not directly 
related to the administration of the state plan.6   
 
Access to information concerning applicants and beneficiaries must be restricted to individuals 
or agency representatives who are subject to standards of confidentiality that are comparable to 
those of the Medicaid or CHIP agency under 42 C.F.R.  431.306(b) and 457.1110(b).  
Accordingly, state policies that implement required restrictions on the use and release of 
information must apply to all data sharing with outside sources, including requests from other 
governmental bodies, the Courts, or law enforcement officials under 42 C.F.R.  431.306(e) 
and 457.1110(b). 
 
Further, states must obtain permission from applicants, beneficiaries or an applicant or 
beneficiarys personal representative whenever possible before making a disclosure of their 
 
5 https://www.whitehouse.gov/wp-content/uploads/2023/01/Federal-Evidence-Agenda-on-LGBTQI-Equity.pdf  
6 Types of civil or criminal charges that are directly related to the administration of the state plan include charges 
related to Medicaid or CHIPs program integrity, such as an allegation of fraud. 
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beneficiary data to an outside source under 42 C.F.R.  431.306(d) or  457.1110, unless the 
information is to be used to verify income, eligibility, and the amount of medical assistance 
payment under section 1137 of the Act and 42 C.F.R.  435.940 through  435.965. Under 42 
CFR  431.306(d) and 457.1110(b), if, because of an emergency situation, time does not permit 
obtaining consent before release, the agency must notify the family or individual immediately 
after supplying the information.  
 
 
SUBMITTING STATE SOGI DATA TO CMS AS PART OF T-MSIS 
 
CMS is targeting calendar year 2025 to begin receiving and accepting SOGI data as part of T-
MSIS data submissions from states that opt to add SOGI questions to their application forms. This 
data will have no impact on a states Outcome Based Assessment score at that time. More 
specificity around CMS readiness and state submission will be provided as requirements for 
receiving and accepting this data are finalized, including instructions for states that are collecting 
SOGI data before the T-MSIS system is ready to accept this data. 
 
 
TECHNICAL ASSISTANCE 
 
CMS remains available to provide technical assistance to states that opt to add SOGI data 
questions to their application. CMS staff are available to review draft materials and participate in 
discussions with states about proposed changes. Questions from Medicaid and CHIP agencies 
regarding this guidance can be directed to Karen Matsuoka, Senior Policy Advisor for Health 
Equity at CMS at Karen.Matsuoka@cms.hhs.gov.  
6