CMS Provides States Guidance on Medical Frailty Verification as Medicaid Work Requirement Implementation Looms
- September 18, 2026
- Written by AHLA Legal Staff
The Centers for Medicare & Medicaid Services (CMS) has released an example approach that states can use to implement the medical frailty exemption to new Medicaid work requirements set to take effect on January 1, 2027.
In a slide-deck posted September 8, CMS detailed a three-tiered framework that appears to hew more closely to verification models for medical frailty that some states had been pursuing before an interim final rule CMS issued in June, see 91 Fed. Reg. 33348.
The rule, which currently is facing a legal challenge from more than two dozen states, includes a “significantly impairs” component to determining whether individuals’ physical, mental, or other behavioral health conditions qualify them for a “medically frail” exemption to the 80-hour per month community engagement requirement that will become a condition of eligibility for certain adult Medicaid beneficiaries next year under the One Big Beautiful Bill Act.
The states have argued that the rule adopts a more restrictive definition of medically frail than the statute envisioned and departs from previous guidance and discussions with federal officials that they relied on in developing their implementation plans.
Under the interim final rule, states must, where possible, verify medical frailty on an ex parte basis using data, for example Medicaid or managed care claims, that they already have without requiring individuals to submit additional information.
The latest CMS guidance details the following framework that states could use for medical frailty verification:
Tier 1: conditions the state can confirm, based on diagnosis alone and without additional documentation, significantly impair an individual’s ability to work (examples include amyotrophic lateral sclerosis (ALS) and end-stage renal disease).
Tier 2: conditions that may indicate an individual is medically frail but require additional information to show significant functional impairment such as acute care utilization, use of durable medical equipment, or other factors like co-morbidities or chronic conditions (examples include individuals with multiple serious chronic conditions in conjunction with high service utilization or repeated inpatient admissions for serious or complex conditions).
Tier 3: available data is lacking or insufficient to establish medical frailty, requiring a manual, individualized assessments where additional documentation may be required such as health records, provider certifications, and managed care plan care management information.
“We encourage states to use the ICD-10 code set to identify diseases, diagnoses, disorders, or other health conditions (conditions) that are likely to identify individuals who may qualify as medically frail in conjunction with functional- and utilization-related code sets that may more accurately identify the severity of a condition,” according to the guidance.
CMS also emphasizes that the tiered medical frailty framework is only an example of various “data-driven approaches” that states could use to verify the exemption.