HCA Outlines Medical Frailty Exemption for Medicaid Work Requirements
Beginning Jan. 1, 2027, most adults ages 19-64 enrolled in Apple Health for Adults will be subject to new federal work requirements. Individuals who are medically frail may be exempt from the requirements. The Washington State Health Care Authority has issued a guidance memo outlining Washington’s approach to implementing the medical frailty exemption under the Medicaid work requirements established by H.R. 1.
Under the federal rule implementing H.R. 1, a diagnosis alone is not sufficient to establish that an individual meets the medical frailty exemption. States must use additional data sources or pathways to demonstrate that an individual meeting the definition of medical frailty is unable to work.
For 2027, individuals will be permitted to self-attest to medical frailty without additional verification. Beginning in 2028, individuals may need to provide documentation when data sources cannot confirm their medical frailty. HCA intends to work with healthcare professionals through 2027 to determine the most effective and least burdensome way to collect this information.
HCA is developing an approach that will use existing claims and utilization data over a defined period to identify individuals who meet the medical frailty criteria. According to HCA, this approach is intended to automate coverage protections for eligible individuals while reducing the need for additional documentation from enrollees and healthcare professionals.
The memo also provides additional details on HCA’s methodology for identifying medical frailty, including its use of diagnosis codes and other claims and utilization information. The agency notes that the diagnosis code list is not exhaustive and is intended to be used in conjunction with other available information. For more resources on the work requirement, visit HCA’s Apple Health (Medicaid) Work Requirement webpage.
The WSMA will continue to monitor and work with HCA on its implementation of the medical frailty exemption and the development of the process for collecting information from providers. With questions and comments please email WSMA Director of Policy Jeb Shepard at jeb@wsma.org.