The Centers for Medicare and Medicaid Services has released guidance showing states how they could identify Medicaid beneficiaries who may qualify for a medical exemption from new community engagement, or work, requirements. The guidance outlines an example three-tier framework, which CMS says is not a mandatory nationwide system.
How states could identify medically frail beneficiaries
Under the example, states could use existing Medicaid claims and health data to help determine whether a beneficiary is medically frail. When that data does not settle the question, additional review may be needed.
An example, not a national requirement
CMS presents the three-tier model as an illustration rather than a required approach. States may use other data-driven methods, so implementation may vary from state to state.
Why severity and function matter
A diagnosis alone does not determine whether someone qualifies. According to the guidance, the severity of a condition and its effect on a person’s functioning can lead to very different outcomes, even when the diagnosis is the same.
