CMS Issues Three-Tier Medical Frailty Verification Model for Medicaid Work Requirements
On September 8, CMS released a three-tier verification framework for states implementing the medical frailty exclusion from Medicaid work reporting requirements. The model allows states to exclude individuals based on diagnosis alone (Tier 1), diagnosis plus utilization or pharmacy data (Tier 2), or individualized review with documentation (Tier 3). This guidance follows CMS's June Interim Final Rule requiring states to assess whether conditions "significantly impair" work ability — a functional standard that expanded beyond diagnosis-based exclusions and created operational challenges for states that had developed automated data strategies. CMS emphasizes the framework is a model, not a mandate, leaving states to select their own methodologies and code sets with clinical teams.