Identifying Medically Frail Individuals: Turning Federal Requirements into State Processes

The federal Medicaid work and community engagement requirements enacted under H.R. 1 exclude medically frail individuals from the population subject to the requirements. The Centers for Medicare & Medicaid Services’ (CMS) Interim Final Rule refines the statutory definition by requiring states to identify individuals with qualifying physical, mental, or behavioral health conditions that also significantly impair their ability to comply with the community engagement requirement. By connecting medical frailty to an individual’s ability to comply, the IFR establishes a more specific standard and provides states with less flexibility than the broader language in H.R. 1.

For an overview of the broader policy, see Aurrera Health’s earlier posts on federal Medicaid work requirements and key implementation considerations for states.

Download the State Action Checklist for key steps states can take to build their medical frailty identification process.

States need an operating model that combines automated identification, consistent decision-making, and an accessible pathway for individuals whose circumstances cannot be verified through existing data. A diagnosis list or standardized documentation form may support that model, but neither can account for differences in how a condition affects an individual’s ability to comply, conditions that are not reflected in available data, or circumstances that require individualized review.

Create a Consistent Statewide Framework

A strong medical frailty framework should translate the federal standard into clear rules that eligibility systems, workers, providers, and members can understand and apply consistently.

States can begin by establishing a multidisciplinary governance team that includes Medicaid eligibility, clinical policy, behavioral health, data, legal counsel, IT systems, and operational leaders. This team should define how the state will operationalize identification, assessment, review processes, and consistency across eligibility channels.

The framework should distinguish between a diagnosis and its functional effect. For example, some conditions may generally establish significant impairment, while others may require additional information about symptoms, treatment, or functional limitations. A simple assessment rubric can help workers apply this distinction consistently without making independent clinical judgments.

Build a “Data First, Ask Second” Workflow

The most effective processes will identify as many medically frail individuals as possible through automated data review without requiring the Medicaid member to act.

The IFR requires states to first attempt to verify medical frailty using reliable information available to the agency, including relevant Medicaid claims and encounter data from the preceding 12 months. States can operationalize this requirement by designing a layered workflow that uses available data to make an initial determination, identifies cases where information is incomplete or unclear for further review, requests additional information only when necessary, routes more complex cases to appropriate clinical or administrative review pathways, and documents the rationale supporting each decision.

States may be able to strengthen this process by combining claims and encounter data with other legally and operationally available information, such as pharmacy, behavioral health, long-term services and supports, disability, or managed care data. Using multiple sources can help identify individuals whose needs would not be evident from a single diagnosis code.

Make the Member Pathway Simple

Administrative data will not identify everyone. Claims may not reflect a recent diagnosis, an untreated condition, care received outside Medicaid, or the extent to which a condition affects daily functioning.

States should therefore create a clear pathway for individuals to request medical frailty consideration online, by phone, by mail, or in person. This pathway should use plain-language questions, identify what the state has already verified, request only the information still needed, and provide assistance to individuals who have difficulty obtaining documentation.

The verification requirements change beginning in 2028. During 2027, states may accept an individual’s statement under penalty of perjury when reliable data is unavailable. Beginning in 2028, states must rely on all available data first. When such data is not available, states must request documentation when it is reasonably obtainable. Only when documentation is not reasonably available may a state accept an individual’s statement under penalty of perjury. In general, this attestation may be used only once during an enrollment period. Designing the member pathway with these requirements in mind will help states transition smoothly to the 2028 standard without creating a separate or confusing process.

Give Providers a Focused Role

Providers may be asked to help establish the nature or functional impact of a condition. States can reduce burden on providers by developing a short, standardized form that asks them to confirm only information relevant to the determination.

Providers should not be expected to interpret Medicaid eligibility rules or decide whether someone qualifies for the exclusion. Their role should be limited to supplying clinical or functional information; the state Medicaid agency should retain responsibility for the determination.

States should also give managed care organizations, providers, and community partners clear information about who may qualify, how to help individuals request consideration, what documentation may be needed, and where to direct questions or complex cases.

Test, Monitor, and Improve the Process

States should test the medical frailty process using realistic scenarios before implementation, including behavioral health conditions, substance use disorders, multiple chronic conditions, incomplete claims histories, and newly diagnosed conditions.

After launch, states should monitor distinct data sets. These measures can help states identify gaps in their condition lists, data logic, notices, or review procedures and support opportunities for targeted improvements. Reviewing outcomes across demographic and geographic groups can also help states identify whether the process is operating consistently.

A successful medical frailty solution will connect policy, clinical expertise, data, technology, eligibility operations, and member support. States that establish a consistent framework, maximize automated identification, and create a low-burden pathway for unresolved cases will be better positioned to protect eligible individuals while meeting federal requirements.

Put these strategies into action

Download the State Action Checklist for key steps states can take to build their medical frailty identification process.

Looking Ahead

Aurrera Health remains committed to advancing access to affordable, comprehensive, high-quality health coverage and care. We provide strategic guidance and technical assistance that helps clients navigate complex policy environments offering support in vision setting, policy development, operational planning, stakeholder engagement, and implementation. States and other stakeholders interested in tailored support related to implementation of new, federally mandated work requirements are encouraged to contact Lauren Block at lauren@aurrerahealth.com for more information.

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Author

Catherine Gekas Steeby [Deputy Director]