As the implementation of the H.R. 1 Medicaid changes approaches, the Centers for Medicare and Medicaid Services (CMS) and the Pennsylvania Department of Human Services (DHS) continue to share information and guidance.
Medical Frailty Exemption
CMS has published a presentation to further clarify how states should implement the medical frailty exclusion for the community engagement requirements that will take effect on January 1, 2027. This
presentation outlines regulatory guidance, verification requirements, implementation options, and examples of how states can identify medically frail individuals using claims and clinical data.
The interim final rule published by CMS in June explained that, for an individual to quality for the medical frailty exemption, they must have a qualifying condition that significantly impairs their ability to comply with work reporting requirements. CMS has provided further clarification on how states can determine medical frailty with an optional three-tiered approach, with:
- Tier 1: Conditions from which the state can confirm an individual’s ability to comply with work reporting requirements based on existing claims and clinical data readily available.
- Tier 2: Conditions that may indicate that an individual is medically frail, but additional information is needed. This could include assessing severity or functional status or other factors indicating impairment, such as co-morbidities, chronic conditions, or acute or temporary conditions.
- Tier 3: Conditions for which there is insufficient or no information or data to assess medical frailty based on Tier 1 or Tier 2 criteria alone. This would trigger a manual, individualized review process where additional documentation may be required to determine exclusion status.
DHS has proposed a similar tiered approach, with three categories to determine a condition’s potential impact on an individual’s ability to comply with work requirements, which includes:
- Category 1: Medically frail based on the presence of a high-risk, severe condition.
- Category 2: Medically frail based on the presence of a chronic condition with additional supporting evidence of severity, complexity, treatment burden, functional impairment, or overall worse health. This category also includes severity indicators to measure the impact on fulfilling work requirements.
- Category 3: Medically frail based on the presence of a significant acute or temporary condition.
CMS generally requires states to use claims and encounter data from the prior 12 months. However, it stated it anticipates allowing a five-year lookback for substance use disorder, recognizing that individuals in stable recovery for more than five years do not qualify under the SUD medically frail category. CMS also clarified that states may accept self-declaration when reliable data is unavailable through January 1, 2028. Beginning on that date, self-declaration generally may be used only once during a beneficiary’s enrollment period.
Retroactive Coverage
Also beginning on January 1, 2027, retroactive coverage timeframes will decrease for Medicaid applicants, with a 30-day retroactive coverage window for Medicaid expansion and a 60-day window for all other Medicaid categories, as opposed to the current 3-month window.
DHS strongly encourages individuals and providers to submit applications for retroactive coverage as soon as possible, specifically no later than the month after services are incurred, or they may not be able to be paid retroactively. Applying as soon as possible will increase the likelihood that the retroactive period is covered. Visit the
DHS Medicaid Toolkit for more information.
RCPA will continue to provide updates as information becomes available. Please contact your Policy Director with any questions.
