Identifying the Population Exempt from Medicaid Work Requirements via Medical Frailty

• In Event: Administrative Burdens in Healthcare: Evidence for Multiple Disciplines

Abstract

Introduction: In 2025, Congress mandated that states implement work requirements for Medicaid enrollees beginning in January 2027. Under the law, persons who are medically frail or who otherwise have special medical needs are exempt from the work requirements mandate. The statute defines this as including individuals who are blind or disabled, have a substance use disorder, a disabling mental disorder, a physical/intellectual/developmental disability significantly impairing ADLs, or a serious or complex medical condition. It also requires states to use reliable information, including claims or encounter data, to implement exemptions without requiring additional documentation from individuals, to the extent possible. States would benefit from a coding framework providing clear guidance as to how to operationalize the medical frailty exemption categories in claims data.

Methods: Using algorithms developed by the Centers for Medicare & Medicaid Services’ Chronic Conditions Warehouse, supplemented by medical frailty definitions incorporated into state Alternative Benefit Plan (ABP) determination processes, we develop a coding framework for identifying persons who qualify for a medical frailty exemption to Medicaid work requirements. Two physicians independently reviewed each algorithm for inclusion or exclusion based on statutory criteria, then met to reconcile their determinations. Where algorithms were deemed to potentially but not certainly meet criteria, ICD‑10 codes within a given algorithm were assessed individually and reconciled as needed. were included if they were: (1) likely to result in ongoing medical care needs OR impairment that limits likelihood of employment, number of hours worked if employed, extent of community participation, or other aspects of economic self-sufficiency; AND (2) are likely to last 6 months or longer (either on their own or as a direct consequence – e.g. acute myocardial infarction and subsequent coronary artery disease); AND (3) are not easily curable with treatment. After this, codes used in state ABP processes not included in the CCW were subjected to a similar process, resulting in a unified algorithm incorporating information from all sources. We then used data from the 2022-2023 Transformed Medicaid Statistical Information System (T-MSIS) to determine the prevalence of medically frail enrollees in each state and to test the degree to which diagnostic categories depended on longer lookback periods in order to identify enrollees within them. 

Results: We will present estimates of both the overall size of the exempt population, the diagnoses that drive utilization under our method, and state-by-state variation in the proportion of the working-age non-pregnant expansion population that can be identified as exempt via claims data using our approach. Preliminary analyses indicate that results are highly sensitive to choice of lookback period, with the use of a 6-month lookback period for identifying claims identifying approximately half the size of the exempt population as compared to a 1-year lookback period.

Discussion/Policy Implications: As states seek to fulfill the statutory requirement to implement Medicaid work requirements, claims data can be a valuable resource for identifying persons who are eligible for a statutory exemption, reducing disenrollment and preserving coverage for vulnerable populations.

Author

• Ari Ne'eman, Harvard University
  Presenting Author