New CMS Framework Helps States Determine Medicaid Frailty Exemptions from Work Requirements
Key Takeaways
- CMS released a new framework to help states determine which Medicaid enrollees qualify for the medical frailty exclusion from community engagement requirements. The guidance clarifies that a diagnosis alone isn't enough; the condition must significantly impair someone's ability to meet work requirements.
- The framework offers states an optional three-tiered approach for assessing frailty, ranging from conditions like ALS or end-stage renal disease that automatically qualify, to cases requiring manual review when data is insufficient. States can adopt this model or create their own data-driven methodology as long as it connects medical conditions to functional impairment.
- All Medicaid expansion states, including partial expansion states like Georgia and Wisconsin, are now implementing these community engagement requirements. The new CMS guidance aims to standardize how states evaluate exemptions while still allowing flexibility in their approaches.
This past week, the Centers for Medicare & Medicaid Services (CMS) released a slide deck to help states interpret and implement the medical frailty exclusion from Medicaid's community engagement requirements. The deck builds on the Interim Final Rule (IFC), which limits the medical frailty exclusion to individuals in one of five statutory categories (blindness or disability, substance use disorder, disabling mental disorder, a physical/intellectual/developmental disability that significantly impairs activities of daily living, or a serious or complex medical condition). Additionally, the IFC requires that the person's condition "significantly impair" their ability to comply with the community engagement requirement. As such, a diagnosis alone is not generally sufficient grounds for an exemption under the rule.
CMS Three-Tiered Framework for Determining Medical Frailty
Under the guidance offered within the newly published deck, CMS lays out an optional three-tiered framework for sorting individuals by how confidently their data supports a frailty determination.
Tier 1: Automatic Determination Based on Diagnosis Codes
Tier 1 involves cases where a single ICD-10 code (e.g., ALS, end-stage renal disease, pancreatic cancer, and HIV with encephalopathy, etc.) is enough on its own to confirm significant impairment.
Tier 2: Additional Data Required for Assessment
Tier 2 includes individuals with a listed condition whose diagnosis code alone doesn't settle the question, prompting states to layer in additional data such as comorbidities, high service utilization, repeated inpatient admissions, or other functional and utilization-based codes (CPT, HCPCS, NDC, etc.) to assess severity.
Tier 3: Manual Review for Insufficient Data
Tier 3 acts as a final catch-all for individuals for whom the state lacks usable data to make a determination and instead requires a manual, individualized review, inclusive of the enrollee having to potentially submit supporting documentation.
Flexibility for States and Ongoing Implementation
Importantly, CMS frames this tiered model as illustrative rather than mandatory. States can adopt it, modify it, or use an entirely different data-driven methodology, as long as it still ties condition to functional impairment and remains auditable. As all Medicaid expansion states, inclusive of partial expansion states of Georgia and Wisconsin, continue down the path of Medicaid community engagement implementation (and refinement in Georgia's case), MultiState is monitoring activity across states. If you have any questions, reach out to any member of the health policy team.
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Medical Frailty Exclusion
The medical frailty exclusion exempts certain Medicaid enrollees from community engagement requirements if they have a qualifying condition that significantly impairs their ability to comply. Under CMS's Interim Final Rule, individuals must fall into one of five statutory categories—blindness or disability, substance use disorder, disabling mental disorder, a physical/intellectual/developmental disability that significantly impairs activities of daily living, or a serious or complex medical condition. A diagnosis alone is not sufficient; the condition must demonstrably affect functional capacity.
Community Engagement Requirements
Community engagement requirements, also known as work requirements, mandate that certain Medicaid enrollees participate in work, job training, education, or community service activities for a specified number of hours to maintain their coverage. These requirements apply to Medicaid expansion populations in states that have received federal approval to implement them. Individuals who meet specific exemption criteria, including the medical frailty exclusion, are not subject to these requirements.
Frequently Asked Questions
What is the medical frailty exclusion for Medicaid community engagement requirements?
The medical frailty exclusion exempts certain Medicaid enrollees from community engagement requirements if they have a qualifying condition that significantly impairs their ability to comply. Under CMS's Interim Final Rule, individuals must fall into one of five statutory categories—blindness or disability, substance use disorder, disabling mental disorder, a physical/intellectual/developmental disability that significantly impairs activities of daily living, or a serious or complex medical condition—and their condition must significantly impair their ability to meet the work requirement. A diagnosis alone is not sufficient; the condition must demonstrably affect functional capacity.
How does CMS's three-tiered framework help states determine medical frailty for Medicaid work requirements?
CMS's optional three-tiered framework sorts individuals based on how clearly available data supports a frailty determination. Tier 1 uses single ICD-10 codes that automatically confirm significant impairment (such as ALS or end-stage renal disease), Tier 2 requires additional data like comorbidities or service utilization patterns to assess severity, and Tier 3 involves manual individualized review when insufficient data exists. States can adopt, modify, or replace this framework with their own data-driven methodology as long as it links condition to functional impairment and remains auditable.
Which states are currently implementing Medicaid community engagement requirements?
All Medicaid expansion states, including partial expansion states Georgia and Wisconsin, are implementing or refining Medicaid community engagement requirements. Georgia is specifically noted as being in a refinement phase of its implementation. The specific timeline and status vary by state as they develop their approaches to medical frailty determinations and work requirement compliance.
Can states use their own methodology instead of CMS's tiered framework for medical frailty determinations?
Yes, states are not required to adopt CMS's three-tiered framework and may use an entirely different data-driven methodology. CMS explicitly frames the tiered model as illustrative rather than mandatory, allowing states to modify it or create their own approach. The only requirement is that any methodology must tie medical conditions to functional impairment and remain auditable for compliance purposes.
What types of data can states use to assess medical frailty under Tier 2 of the CMS framework?
States can layer in multiple data sources including comorbidities, high service utilization patterns, repeated inpatient admissions, and various functional and utilization-based codes such as CPT, HCPCS, and NDC codes. This additional data helps states assess the severity of a listed condition when the diagnosis code alone doesn't definitively establish significant impairment. The combination of data points allows for a more comprehensive evaluation of whether an individual's condition significantly impairs their ability to comply with community engagement requirements.