The Centers for Medicare & Medicaid Services (CMS) on Sept. 8 released guidance on implementing the medical frailty exclusion under the community engagement requirements from the Working Families Tax Cut legislation (WFTCL).
The guidance expands on the definition of medical frailty in the interim final rule, the verification process, tiered medical frailty framework, managing exclusions with data sources or codes, and other information.
Individuals may qualify for the medical frailty exclusion if they:
- Are blind or disabled (as defined in section 1614 of the Social Security Act)
- Have a substance use disorder (SUD)
- Have a disabling mental disorder
- Have a physical, intellectual, or developmental disability that significantly impedes their ability to perform one or more activities of daily living
- Have a serious or complex medical condition
Tiered Medical Frailty Framework
States may adopt a tiered approach based on available data to organize qualifying conditions using the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) for medical frailty. States are responsible for identifying all types of data and codes that could relate to the presence of the condition. Relevant data may include fee-for-service claims, managed care encounters, health information exchanges, health data utilities, and/or all-payer claims.
- Tier 1: Sufficient information is readily available to confirm that the condition significantly impaired the individual’s ability to comply with the community engagement requirement.
- Tier 2: Some information is available indicating potential medical frailty, but additional information is needed to determine if the condition significantly impairs compliance.
- Tier 3: There is insufficient or no information or data to assess medical frailty based on Tier 1/Tier 2 criteria alone. This should trigger a manual individualized review and potentially require additional documentation, which may include but is not limited to:
- Health records such as medical history, treatment records, progress notes, discharge paperwork, medication lists, and lab or other diagnostic test results
- Provider documentation or certification, managed care plan care management information, and/or level of care or functional assessment information that is not in a state’s administrative data
Before Jan. 1, 2028, states have the option to accept self-attestation under penalty of perjury each time they verify an individual’s medically frail status. After this date, the state may accept self-attestation only once per enrollment period.
SUD Medically Frail Category and Recovery
CMS notes that the SUD medically frail category excludes individuals in recovery for five or more years. For individuals in recovery for less than five years, the state must determine that the SUD significantly impairs their ability to comply with the community engagement requirement. States may verify medical frailty using claims adjudicated in the preceding 12 months. CMS also anticipates allowing states to review claims and other data from the preceding five years to confirm that an individual has been in recovery for less than five years, despite the requirement that adjudicated claims and encounter data come from the preceding 12 months.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions or for more information.
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