Key State Policy Choices About Medical Frailty Determinations for Medicaid Expansion Adults

Since 2006, states have had to determine “medical frailty” for Medicaid enrollees if states choose to design an “alternative benefit plan” (ABP, previously called a benchmark benefit package) that differs from the traditional state plan benefit package. To date, there are 12 states that must determine medical frailty because they offer an ABP for Medicaid expansion adults. The medical frailty determination is intended to protect coverage for enrollees who have physical and/or mental health needs but do not qualify for Medicaid based on a disability. Medical frailty determinations are assuming greater importance in recent years as more states adopt restrictive Section 1115 waiver policies, such as premiums or work requirements. CMS has required many, but not all, of these states to identify and exempt enrollees who are medically frail from restrictions on coverage and benefits under these waivers. This issue brief answers three key questions about medical frailty determinations and presents new data on the rules and processes used by the 12 states making these determinations for Medicaid expansion adults. The findings are based on a 50-state survey conducted by the Kaiser Family Foundation’s Program on Medicaid and the Uninsured in fall 2018. Tables contain state-level data for the 12 states.

Key findings include the following:

  • A dozen states, or about one-third of Medicaid expansion states, must identify enrollees who are medically frail because these states provide a benefit package to expansion adults that differs from the traditional state plan benefit package. The medical frailty process is intended to ensure that these enrollees receive the benefit package that best meets their needs. Key areas that may differ include home and community-based services, behavioral health, and preventive services.
  • Medical frailty determinations are assuming even greater importance for enrollees’ ability to retain the coverage and scope of benefits for which they are eligible, as some states implement Section 1115 waivers that impose restrictions on eligibility and benefits. Currently, six states must determine medical frailty to exempt these enrollees from restrictive waiver policies such as work requirements and premiums.
  • The complexity of the administrative process for determining medical frailty can affect enrollees’ ability to retain access to the benefit package and coverage for which they are eligible. Policy developments in this area will be important to watch, as Medicaid expansion and implementation of restrictive policies in Section 1115 waivers continues.
Issue Brief

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