Recent guidance from the Centers for Medicare and Medicaid Services (CMS) permits states to implement a tiered system for categorizing Medicaid recipients based on their medical frailty. This change aims to determine who cannot meet the work requirement of 20 hours per week due to their health conditions.
This development follows discussions with state Medicaid leaders and was made public via a recently released document. It offers some relief to patient advocacy groups that have criticized previous medical frailty exemptions as convoluted and burdensome for both patients and healthcare providers.
Benjamin Sommers, a Harvard University professor and primary care physician, described the guidance as "somewhat more encouraging," as it allows the use of existing data to automatically exempt some patients. Yet, concerns remain that individuals with significant health issues may still face bureaucratic obstacles that could jeopardize their health coverage. Preliminary data from the Congressional Budget Office warns that over 7 million individuals could lose access to Medicaid in the forthcoming years.
According to H.R. 1, passed last year, states expanding their Medicaid programs must validate that working-age recipients meet the 20-hour work criterion, unless they fall into specific categories such as being disabled or caretakers. Chronic illness advocates have voiced their anxiety over proving their incapacity to work due to their conditions.
The newly issued guidance allows states to compile lists of diagnostic codes indicating medical frailty, and organize them into tiers where severity impacts the exemption process. For instance, conditions like end-stage renal disease, ALS, or late-stage cancer are classified in the highest tier, signifying that no further documentation is required for an automatic exemption. This tier designation indicates these severe diagnoses inherently preclude individuals from maintaining regular work or daily activities.
Tier 2 conditions may indicate medical frailty, but may necessitate additional verification, such as bills for recent treatments or specific medication codes. Individuals with serious chronic conditions who frequently use medical services or have repeated hospitalizations may also fall into this tier. The tier distinctions may vary depending on each patient's circumstances; for example, one individual with vision loss due to type 2 diabetes may qualify for Tier 1 while another, with various complications and on multiple medications but without hospital admissions, might end up in Tier 3, which requires individual case reviews.
States are not mandated to adopt this tier system, but given their need to establish eligibility verification systems by January 1, it offers them more flexibility in managing these requirements.
The American Medical Association commented that this data-driven strategy could lessen the documentation burden on both beneficiaries and doctors, a necessary adaptation in light of ongoing demands from CMS to clarify procedures for exhibiting medical frailty. Should diagnostic codes alone suffice in demonstrating medical frailty, doctors wouldn't have to submit additional paperwork, which many believe is impractical under the current system.
As a result, advocacy groups are actively lobbying for more appropriate classifications within the tier system. Achieving a higher tier could significantly lessen the paperwork requirements for patients and mitigate the risk of losing their coverage.
#MEAction, a network for individuals affected by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), as well as related conditions like long Covid and postural orthostatic tachycardia syndrome (POTS), has engaged with numerous state Medicaid officials to stress the unique challenges faced by its community. The experience of individuals with complex and poorly understood health conditions often means they navigate lengthy paths to diagnosis, despite significant declines in their health status.
The upcoming changes to work requirements allow individuals to self-affirm their conditions for the first year. However, by 2028, more rigorous documentation will be necessary to maintain their frailty exemptions, creating what #MEAction Campaigns Director Ben HusuBorger refers to as "two cliffs."
States like Nebraska, Montana, and Arkansas have begun implementing work requirements, but there's no available data reflecting how many individuals may have lost their coverage thus far. Iowa plans to commence its implementation on December 1, while other states are set to follow by January 1.
CMS is also facing legal challenges from numerous states arguing that the work requirements and the burden of proving medical frailty are unlawful.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.