The Centers for Medicare & Medicaid Services (CMS) issued new guidance on Sept. 8 that provides states with a framework for implementing the medical frailty exclusion (PDF) in Medicaid work and community engagement requirements, as required by the One Big Beautiful Bill Act (OBBBA, P.L. 119-21, PDF). This guidance follows an interim final rule released by the agency in June, which required states to determine whether an individual’s condition significantly impairs their ability to meet the requirement that certain adults complete 80 hours per month of qualifying activities, such as employment, enrollment in an educational program, or community service, to maintain eligibility for Medicaid [refer to Washington Highlights, June 5].
In this guidance, the CMS outlined a three-tiered approach for states to identify individuals who may qualify as medically frail: Tier 1, diagnoses that may independently establish the presence of a condition and if the condition impairs an individual’s ability to work; Tier 2, conditions that may establish medical frailty when paired with supplemental information (e.g., utilization data, comorbidities); and Tier 3, cases that would proceed to individualized manual review where additional documentation may be required.
States must implement the OBBBA’s Medicaid work and community engagement requirements by Jan. 1, 2027.