State defines medical frailty for Medicaid

Indiana state officials on Tuesday detailed the method they will use to identify Medicaid expansion enrollees who qualify for a medical frailty exemption. The exemption allows eligible individuals to skip new work requirements that take effect on January 1. The state will rely on a computerized tool to review claims data and make initial determinations.

The Healthy Indiana Plan serves approximately 475,000 residents, with 355,000 of those adults falling into the expansion population. These individuals earn slightly too much for traditional Medicaid but face strict conditions to keep their coverage. Starting next month, they must show they worked, volunteered, or attended school for 80 hours per month for the preceding three months. Alternatively, earning at least $580 per month satisfies the requirement.

Federal rules narrow the definition of medical frailty to five specific categories. These include blindness or disability under the Social Security Act, physical or developmental disabilities, disabling mental disorders, substance use disorders, and serious medical conditions. A participant is only considered frail if their condition significantly impairs their ability to meet the work standards. State officials estimate that nearly 140,000 current enrollees will qualify for the exemption.

The state will use a tool called Milliman Advanced Risk Adjusters, or MARA, to process this data. Chief Clinical Officer Katrina Etter said the software was customized to match the new federal definition. The system operates in two automated tiers. Tier 1 identifies members based on specific diagnoses on a state list. Tier 2 reviews those diagnoses alongside the treatments and services the member is currently receiving.

If the automated system does not classify a participant as frail, they can submit additional information for manual review. This third tier allows a participant, provider, or managed care organization to request a decision. State clinical staff will examine medical records, lab results, and treatment notes to make a final call. Medicaid Chief Operating Officer Lindsey Lux noted that this path is available for those not captured by the initial algorithm.

The current clinical team handling these manual reviews consists of three full-time staff members. Etter said the team will grow as needed based on the volume of cases received through the third tier. Officials are also updating online guidance and creating necessary forms to support the process.

MARA will run again next month. The state plans to mail determination notices to enrollees by late November or early December. These letters will inform recipients whether they are deemed medically frail and exempt from work requirements. If a participant receives a notice stating they are not frail, it will include instructions on how to submit information for a manual review.

Family and Social Services Administration Secretary Mitch Roob noted that a large portion of the estimated frail population qualifies due to disabling mental disorders. He explained that waivers for substance use disorders and serious mental illnesses were added to the program during the administration of former Gov. Mike Pence. Roob stated that this coverage was intentional in response to the rise in substance use disorders and remains a core part of the plan.