How States Can Design Accessible Processes to Prevent Coverage Loss for Eligible Individuals
By Marcella Maguire, Ph.D., Director, Health Systems Integration at CSH
As outlined in our previous post, H.R.1—the “One Big Beautiful Bill”—makes significant changes to Medicaid and creates new barriers to health insurance coverage for people who rely on the program. CSH is developing a decision tree to help your agency use every available strategy to ensure all eligible people keep their coverage as state Medicaid eligibility requirements change. Our goal remains the same: continuous healthcare coverage for everyone who qualifies under the new law. When coverage lapses and people become uninsured, they face significant challenges accessing needed health care, medications and supportive services. Losing coverage also makes it far more difficult to access treatment and maintain recovery.
People who are covered by Medicaid solely due to low income—commonly called the “Medicaid Expansion” population—face the most significant new barriers under H.R.1. Our previous posts outlined several of these challenges, including work requirements, more frequent eligibility determinations, and new address verifications processes. This next blog focuses on one strategy states can use to help eligible individuals keep their coverage: the “Medical Frailty” designation.1
HR1 identifies people who are “Medically Frail” as exempt from work requirements. Section 71119 (a)(9)(A)(ii)(V) defines this group a person:
“who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual— ‘‘(aa) who is blind or disabled (as defined in section 1614); ‘‘(bb) with a substance use disorder; ‘‘(cc) with a disabling mental disorder; ‘‘(dd) with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; or ‘‘(ee) with a serious or complex medical condition.”2
States must make several decisions when implementing a Medical Frailty process. CSH encourages states to make choices that limit administrative burden on enrollees and prevents eligible people from losing coverage.
Key state decisions include:
- Is there a state Medical Frailty designation?
- If a state has chosen to make this designation, how will it define Medical Frailty?
- How does a person prove Medical Frailty—what documentation is required, and how long will the designation remain valid?
DOES YOUR STATE HAVE A MEDICAL FRAILTY DESIGNATION?
States develop their own processes to define Medical Frailty3 in more detail and determine who qualifies. For example, federal law states that a person with a “disabling mental disorder” qualifies, but states must decide whether that includes people with anxiety diagnoses, personality disorders, or Post Traumatic Stress Disorder. Many states use the Medically Frail designation to align eligibility for this group with the benefits available to people considered disabled by the Social Security Administration. States that adopt this designation use it for the many people who are in the process of applying for Supplemental Security Income (SSI) or Social Security Disability Income (SSDI).
As of 2025, CSH is aware of 12 states that use a Medically Frail designation: Arkansas, California, Indiana, Iowa, Massachusetts, Michigan, Montana, Nevada, New Hampshire, New Jersey, North Dakota, and West Virginia.4
States not on this list can create their own designation through legislation or Medicaid agency regulations. Resources such as Manatt Health’s Implementation Toolkit for States and the Medical Frailty Project Workplan can guide this process. This process includes critical feedback from People with Lived Expertise (PLE) who are current or past Medicaid beneficiaries.
HOW DOES YOUR STATE DEFINE MEDICAL FRAILTY?
Federal law requires five broad, high-level categories of Medical Frailty. To minimize coverage loss, advocates should consider how state definitions can ensure this designation includes all eligible individuals. The required categories include people who are:5
- Active in substance use disorder (SUD) treatment
- Living from a disabling mental disorder
- Experiencing a physical health condition or intellectual or developmental disability (IDD) that impairs ability in at least one Activity of Daily Living (ADL)
- Managing a serious or complex medical conditions
- Aged, blind or disabled as defined by the Social Security Act
States determine how detailed or broad their definitions and documentation requirements will be. States also may choose to actively communicate about this designation and train key partners—such as hospitals, health centers, housing and homeless agencies—to ensure all who qualify will be aware and can benefit from the designation.
HOW DOES A PERSON PROVE THEY ARE MEDICALLY FRAIL?
States must begin to require this documentation of community engagement activities and work beginning December 31, 2026. However, advocates should know that states are actively engaging with stakeholders and planning these systems now.
States face several decisions in this process. For example, a state’s Medicaid claims system is usually separate from its eligibility and enrollment systems. States vary in how well these separate systems communicate with each other. When data can be shared easily, information from one system can be used to confirm compliance with another system’s requirements. Some states are also integrating Medicaid data with additional systems—such as state tax systems, which verify income and work hours, or SNAP systems,6 which have similar work requirements.7
Federal rules require states to use the ex parte process whenever possible. This means states should automatically verify eligibility using available data rather than asking individuals to submit paperwork. Under this approach, a diagnosis coded in a Medicaid claims system—such as one that meets the definition of a “disabling mental disorder”—could automatically qualify someone as Medically Frail. The individual would receive the exemption from work requirements without taking any action.
States may also differ in the burden they place on the individual to gain this designation. Some states may require a physician evaluation, while others allow any Licensed Practitioner of the Healing Arts (LPHA) to sign the required forms. States may or may not require an in-person interview with a state eligibility worker. The more steps and requirements in the process, the more likely eligible people will lose coverage and, consequently, access to essential services.
States may also have a process of Application Assisters or navigators to help people complete this process. States can authorize, train, and even fund these roles. Washington State is a great example of a state that has effectively built out this role.8 Application assisters can access limited information in a person’s state benefits account, receive email alerts when action is needed to maintain coverage, and help upload required documents. In states with more complex Medical Frailty processes, these application assisters can be critical supports to ensure people successfully and compliantly navigating this process.
THE PATH FORWARD
For those who quality, a Medical Frailty designation can exempt someone from work requirements and other barriers to health insurance coverage via Medicaid. Because the stakes are high, states must make thoughtful choices in designing their processes. States that prioritize continuous coverage should consider the issues outlined above. Advocates can use these ideas to influence their state’s decisions and help ensure people who are entitled to Medicaid coverage can keep it, even as H.R.1. creates new barriers.
