Understanding medical frailty in Medicaid: What the New Interim Final Rule means for coverage

For the first time in Medicaid’s history, adults ages 19-64 who are enrolled through Medicaid expansion will be required to complete and document at minimum 80 hours of qualifying activities per month, or risk losing their coverage. This, according to the provisions of H.R. 1, better known as the “One Big Beautiful Bill” Act, signed into law on July 4, 2025. The Centers for Medicare and Medicaid Services (CMS) will implement work requirements beginning January 1, 2027.

The new requirement ensures that certain populations are exempt from work requirements, including individuals who are considered medically frail. However, a point of contention since the release of CMS’s Interim Final Rule (IFR) this past June has been its definition of medically frail. Although there are exemptions for medically frail individuals, advocates, health policy experts, and even some states question whether CMS’s interpretation of congressional intent creates a more nuanced and restrictive standard.

The concern is that the IFR requires individuals not only to demonstrate that they have a qualifying condition, but also that their condition impairs their ability to meet the work requirements—potentially making it more difficult for those individuals with serious health conditions to qualify as medically frail. This raises three important questions:

1. How will states determine medical frailty?
2. How do individuals qualify for the medical frailty exemption?
3. What can individuals do to prepare for this change?

How will states determine medical frailty?

The IFR requires states to identify those who may qualify as medically frail by using existing information such as Medicaid claims data. Additionally, it is expected that states develop and maintain lists of medical conditions and diagnosis codes that can be used to identify individuals. However, simply having a qualifying condition alone does not guarantee exemption.

There are 690,034 Ohioans directly affected by this change.

States will have to determine if the individual’s condition significantly impairs their ability to meet the work requirements. To accomplish this, the IFR explains that states may accept provider documentation and other information demonstrating medical frailty.

How do individuals qualify for the medical frailty exemption?

According to the IFR, there are five ways to qualify as medically frail:

1. Blind or disabled under Social Security rules
   
   1. NOTE: Individuals who are blind and disabled may already qualify for Medicaid through another eligibility group.
2. Substance use disorder with less than 5 years of stable recovery
3. Disabling mental health condition
4. Individuals with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more Activities of Daily Living (ADLs)
5. Serious or complex medical condition
   
   • Cancer
   • End stage renal disease
   • HIV/AIDS
   • ALS/Parkinsons
   • Multiple sclerosis
   • Sickle cell disease
   • Cystic fibrosis

It is worth noting that the IFR does make clear that states cannot automatically deny a medically frail exemption if the condition or diagnosis is not on the states list of qualifying diagnosis codes.

Individuals who will seek a medical frailty exemption do not have to wait until then to begin preparing; rather there are several steps that can be taken now.

What can individuals do to prepare for this change?

There are 690,034 Ohioans directly affected by this change. While states are preparing to implement this new rule by January 1, 2027, individuals who will seek a medical frailty exemption do not have to wait until then to begin preparing; rather there are several steps that can be taken now: 

1. Ensure your contact information is current with Medicaid and/or your managed care plan
2. Pay attention to all notices from Medicaid and respond accordingly
3. Request and maintain documentation from your health care providers 

Conclusion

As Ohio moves toward implementation, understanding medical frailty becomes all the more important for the program's participants. While the exemption is aimed at helping individuals with serious health conditions, how this IFR is interpreted and ultimately implemented will certainly determine who loses and maintains their coverage. The Center for Community Solutions will continue to monitor developments pertaining to this IFR and will provide additional analysis as guidance becomes available from the Ohio Department of Medicaid and CMS.