CMS lets states tier Medicaid frailty exemptions — SkimNews
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- CMS released guidance allowing states to use a three-tier system to identify Medicaid recipients too medically frail to meet work requirements, with Tier 1 conditions like end-stage renal disease, ALS, and end-stage cancer automatically exempting patients with no additional paperwork.
- Tier 2 and Tier 3 designations require progressively more documentation: Tier 2 conditions need supporting data such as recent acute care billing or pharmacy codes, while Tier 3 illnesses undergo case-by-case review by states.
- The Congressional Budget Office preliminarily estimates over 7 million people will lose Medicaid coverage in coming years, and Harvard's Benjamin Sommers warned the approach is still complicated and sick people could get caught in red tape.
- The American Medical Association called the data-driven approach encouraging and said it could reduce documentation burdens on physicians and beneficiaries who had faced an 'unrealistic' paperwork requirement under earlier proposals.
- #MEAction is lobbying state Medicaid directors for better tier placement for ME/CFS, long Covid, and POTS conditions, warning patients face 'two cliffs' — self-attestation allowed through 2027, then formal documentation required starting 2028 for illnesses that often take years to diagnose.
- Nebraska, Montana, and Arkansas have begun implementing work requirements early; Iowa starts Dec. 1 and all other Medicaid expansion states are set for Jan. 1.
- Roughly two dozen states are suing CMS alleging the work requirements and the medical frailty documentation burden are unlawful.
Why it matters: Patient advocates had warned that proving medical frailty under H.R. 1 would be impossibly burdensome for chronically ill people, risking coverage loss for millions. The tier system lets states lean on existing diagnostic codes rather than forcing patients and doctors to generate new paperwork — but CBO still projects over 7 million people will lose Medicaid, and two dozen states are simultaneously suing to block the requirements.
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