When Congress included major reductions in Medicaid eligibility in last year’s budget reconciliation bill – H.R. 1, often referred to as the “One Big Beautiful Bill Act” – it included one criterion for Medicaid eligibility that immediately proved challenging. While the new law requires individuals to work or participate in “community engagement” activities such as attending school or performing volunteer work” as a condition of Medicaid eligibility, it offered an exception to this requirement: those found to be “medically frail.”
The law, however, did little to define what constitutes medical frailty beyond defining as medically frail those who are blind or disabled, have a disabling mental disorder or a substance use disorder, have a serious or complex medical condition, or have a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living. This left a considerable gray area: the states would need to define what specific conditions circumstances are included under some of the less-specific categories.
Recognizing this challenge, the Centers for Medicare & Medicaid Services has published some guidance on the concept of medical frailty and how states may choose to define it – if they wish – in its new document “Implementing Medical Frailty Under Community Engagement (Section 71119 of WFTC Legislation).”
In the guidance document, CMS establishes three tiers of medical conditions that may – if they impair an individual’s ability to work – qualify a Medicaid applicant as medically frail.
- Tier 1 covers diagnoses that both establish one of the covered medical diagnoses and the conclusion that the particular diagnosis would impair the applicant’s ability to work.
- Tier 2 suggests meeting the criteria for medical frailty if accompanied by additional information, such as prescription drugs, use of durable medical equipment, health care utilization data, or other clinical data.
- Tier 3 suggests that states may have latitude for interpretation in situations that cannot be addressed through available data and require more individual review and additional documentation.
These tiers are presented by CMS to the states for their consideration. They are not required.
How states ultimately define medical frailty has potentially significant implications for community safety-net hospitals because those hospitals traditionally serve more Medicaid and low-income patients than the typical hospital. Loss of Medicaid coverage in their communities could result in an increase in how much uncompensated care they provide.
CMS presents these tiers in greater detail in the guidance document “Implementing Medical Frailty Under Community Engagement (Section 71119 of WFTC Legislation),” which includes lists of utilization and data sources that can be used to help determine whether individual applicants can reasonably be considered medically frail. Learn more from that document and the article “CMS Releases New Information on Operationalizing Medicaid Work Reporting Requirements’ Medical Frailty Exclusion” published by the organization State Health and Value Strategies.
