CMS has given states a new way to determine which Medicaid recipients are medically frail and therefore exempt from the new requirement to work or volunteer at least 20 hours a week.
The new guidance divides medical conditions into three tiers.
-
Tier 1 includes conditions so severe that the diagnosis itself establishes that a person cannot work or perform daily activities; no additional documentation is required.
-
Tier 2 includes conditions that may indicate medical frailty but require additional evidence from existing data, such as recent acute-care visits, hospitalizations, or pharmacy and medication records.
-
Tier 3 conditions require an individualized, case-by-case review.
States are not required to use the tier system, but they are under pressure to establish their eligibility systems by January 1.
This is particularly concerning for people with ME/CFS and other poorly understood chronic illnesses. Many people with ME/CFS remain undiagnosed for years despite substantial disability. During the first year, people can self-attest to their condition, but beginning in 2028 they will need documentation to maintain the medical-frailty exemption.
ME/CFS may be especially vulnerable to the lower tiers because severe disability does not necessarily produce the kinds of administrative data used to establish medical frailty—such as hospitalizations, acute-care utilization, or medication records. A patient who is too sick to work may nevertheless have little conventional medical evidence of that disability.
MEAction has contacted state Medicaid directors and is advocating for better placement of ME/CFS and related conditions, including Long COVID and POTS, within the tier system. A higher tier could mean less paperwork and a lower risk of losing coverage.
(paywalled)