Medicaid work rules exempt the ‘medically frail.’ Deciding who qualifies is tricky

By Samantha Liss and Sam Whitehead KFF Strength News Eliza Brader worries she soon will need to prove she s working to continue receiving Medicaid healthcare coverage She doesn t think she should have to Related Articles Affordable Care Act enrollment is slightly ahead of last year so far despite expiring subsidies AI vs AI Patients deploy bots to battle fitness insurers that deny care After series of denials his insurer approved doctor-recommended cancer care It was too late Madrigal Medicare Advantage long overdue for a checkup MassDems call on Republican governor candidates to denounce RFK Jr vax vote The -year-old resident of Bloomington Indiana has a pacemaker and a painful joint sickness She also has fused vertebrae in her neck from a spinal injury preventing her from turning her head Indiana s Medicaid agency as of now considers Brader medically frail giving her access to an expanded set of benefits such as physical therapy New federal rules will require more than million Medicaid enrollees nationwide to show they re working volunteering or going to school for hours a month starting in to keep their coverage Brader is exempt as long as she s deemed medically frail But lacking sufficient federal guidance states are wrestling with how to define curative frailty a consequential decision that could cut Medicaid coverage for a great number of people disclosed state agents consumer advocates and medical plan researchers It s terrifying Brader stated I already have fought so hard to get my fitness care Incredibly High Stakes President Donald Trump s One Big Beautiful Bill Act slashes nearly trillion from Medicaid over the next decade with much of the savings projected to come from no longer covering those who don t qualify under the new work rules Those spending cuts help offset the costs of GOP priorities such as extra confines assurance and tax cuts that mainly benefit the wealthy Conservative lawmakers have argued that Medicaid the regime strength insurance operation for people with low incomes or with disabilities has grown too large and expensive especially in the wake of its expansion to more low-income adults under the Affordable Care Act They also say that requiring participants to work is common sense The work rules in Trump s tax-and-spending law offer exemptions for several groups who might struggle to meet them including people deemed medically frail The law spells out certain medically frail conditions such as blindness disability and substance use disorder But it does not list countless others Instead the law exempts those with a serious or complex anatomical condition a term whose interpretation could vary by state State representatives say they need more clarity to ensure that people who cannot work for wellbeing reasons retain rightful access to Medicaid They also worry that even with a clear definition people will face the onerous task of having to regularly vouch for being medically frail which is a challenge without reliable access to health care The stakes are incredibly high explained Kinda Serafi a partner at consulting firm Manatt Wellbeing The new work requirements will affect Medicaid recipients in states and Washington D C Eight states Alabama Florida Kansas Mississippi South Carolina Tennessee Texas and Wyoming did not expand their Medicaid programs to cover additional low-income adults so they won t have to implement the work rules The Medicaid work rules are expected to be the largest driver of physical condition insurance coverage losses over the next decade according to the nonpartisan Congressional Budget Office Forty-four percent of all adults covered by states expanded Medicaid programs have at least one chronic medical condition according to KFF A Challenge for States State Medicaid agencies are scrambling to implement the rules with little direction from the U S Department of Vitality and Human Services which has yet to issue specific guidance Federal agents will clarify the medically frail definition next year announced Andrew Nixon an agency spokesperson Ultimately states will have to decide who is unhealthy enough to be exempt from work rules And it won t be easy for state workers and their computer systems to track Every year state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other regime programs Now these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules Jessica Kahn a partner at consulting firm McKinsey Co has urged states to start planning how to adapt eligibility systems to verify work status States can do a tremendous amount of work without direction from the federal authorities stated Kahn a former federal Medicaid systems official who spoke during a latest Medicaid advisory panel hearing Time is a-wasting already State Medicaid directors are pondering the challenge Healthcare frailty gets so complex Emma Sandoe Oregon s Medicaid director commented during a new panel discussion Conditions that can keep people from working such as mental physical condition disorders can be hard to prove she mentioned A state might try to use figures pulled from a person s physical condition records for instance to determine clinical frailty But information from a victim s chart may not paint a clear picture of someone s healthcare especially if they lack regular access to physiological care It s a tall order for eligibility systems that historically have not had to scrape physiological records to screen applicants declared Serafi of Manatt Vitality That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all Serafi revealed Lobbying groups for the private physical condition insurance companies that help run Medicaid in countless states also have urged federal regulators to clearly define physiological frailty so it can be applied uniformly In a Nov letter to federal executives the Medicaid Wellbeing Plans of America and the Association for Society Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail Successfully implementing exemptions for the medically frail will be crucial given the severe robustness risks of coverage loss for these populations the groups disclosed A few state officers worry about unintended consequences of the work rules for people with chronic conditions Jennifer Strohecker who in the last few days resigned as Utah s Medicaid director reiterated the high stakes especially for those with diabetes on Medicaid They may be very healthy and functional with insulin but if they fail to complete the work requirements that may change Strohecker explained during a latest Medicaid advisory hearing Whether someone is deemed medically frail already depends heavily on where they live For example in Arkansas people indicate on their Medicaid applications that they re disabled blind or need help with daily living sessions Approximately of the roughly people enrolled in Arkansas Medicaid expansion effort are deemed medically frail according to Gavin Lesnick a spokesperson for the Arkansas Department of Human Services In West Virginia the state accepts a health frailty designation when an applicant self-reports it The burden of proof is higher in North Dakota Applicants there must answer a questionnaire about their fitness and submit additional documentation which may include curative chart notes and rehabilitation plans More than half of applicants were denied last year according to Vitality and Human Services Department spokesperson Mindy Michaels Indiana s Family and Social Services Administration which runs its Medicaid activity declined an interview and commented it could not comment on individual cases like Brader s Brader worries the additional red tape will cause her to lose Medicaid again She disclosed she was temporarily kicked off the venture in for failing to meet the state s work rules when Indiana disclosed her work-study job didn t count as employment Anytime I have tried to receive help from the state of Indiana it has been a bureaucratic nightmare she stated As states await federal guidance Kristi Putnam a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services which oversees the state Medicaid scheme commented even if a state creates an extensive list of qualifying medically frail conditions the line must be drawn somewhere You can t possibly create a protocol for exemptions that will catch everything she announced KFF Healthcare News Distributed by Tribune Content Agency LLC