Medicaid introduces tier system to determine medical frailty

The Centers for Medicare and Medicaid Services has released new guidance allowing states to implement a “tier system” to determine medical frailty. This system is designed to identify Medicaid recipients who are too ill to meet the 20-hour-per-week work or volunteer requirement mandated by H.R. 1.

Under the new guidance, states can use diagnostic codes to categorize illnesses. High-tier diagnoses, such as ALS, end-stage renal disease, or end-stage cancer, would allow for automatic exemptions from work requirements. While some medical professionals suggest this use of existing data is encouraging, others warn that the administrative process remains complex and could still lead to vulnerable patients losing coverage.

Individual cases highlight the stakes of these policies. In Montana, a cancer survivor in remission lost her Medicaid disability coverage after state officials determined she was no longer eligible, a decision made after she stopped receiving Social Security disability payments in hopes of returning to work. Advocates express ongoing concern that the administrative hurdles required to prove disability may cause many chronically ill individuals to lose essential health insurance.