New Medicaid Work Rule Narrows Medical Frailty Exemption

The Centers for Medicare and Medicaid Services released an interim final rule last week that narrows the medical frailty exemption under new Medicaid work requirements scheduled to begin January 1. Expansion enrollees ages 19 to 64 must work, volunteer, or attend school at least 80 hours a month unless they meet the revised exemption standard.

The rule defines medical frailty as a condition that must “significantly impair” a person’s ability to meet those hours. Patients can attest to meeting the definition in 2027 and once in 2028, but must provide documentation when renewing coverage in 2028.

States had planned to use Medicaid claims data to identify eligible people automatically. CMS told The Associated Press that verification through claims data or other documentation will generally be required and that states may not categorically exclude individuals based solely on a diagnosis.

State Medicaid officials and consultants said existing claims data do not show whether a condition significantly impairs work capacity. One consultant working with states said systems lack the information needed to make the required determination.

DeAnna Brandon, a 48-year-old blood cancer survivor in Rockwell, North Carolina, said she is unsure whether her symptoms of extreme exhaustion and memory challenges will qualify under the new standard. She said working is outside the realm of possibility and that gathering documentation from multiple doctors would be physically and emotionally difficult.

Sarah Maresh of Nebraska Appleseed said rural doctors already reluctant to accept Medicaid patients may stop taking them if additional certification steps are required. A $200 million federal allotment is available to states, though an AP analysis estimated total technology and staffing costs will exceed $1 billion.

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