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Medical Frailty

Medical Frailty

Under new federal rules, some people with Healthy Michigan Plan coverage will need to meet work requirements to keep their health care coverage. Someone who is considered medically frail under these rules is exempt from meeting work requirements.

Follow this link for a complete list of exemptions.

What “medically frail” means

An individual is considered medically frail if they have a physical, mental, or behavioral health condition that makes it hard to meet work requirements.

The federal law (H.R.1) defines medically frail individuals as people with:

  •        Blindness or a physical or mental disability
  •        A substance use disorder, or who are in recovery within the past five years
  •        A disabling mental health condition
  •        A physical, intellectual, or developmental disability that limits daily activities
  •        A serious or complex medical condition 

 

How MDHHS identifies medically frail individuals

MDHHS will identify individuals with medically frail conditions in two ways: through Medicaid healthcare data or through self‑attestation.

Healthcare Data

MDHHS reviews Medicaid claims, encounter data and certain other program enrollment information. This includes services covered by Medicaid Health Plans and Prepaid Inpatient Health Plans.

MDHHS uses a list of health conditions, treatments, major procedures, and specialized medical equipment that can show a person’s health needs make working difficult.

Self-attestation

If a person’s health condition is not shown in MDHHS data, they can report it by responding to questions regarding medically frail conditions during application, renewal, or when updating their information in MI Bridges.

  • In 2027, MDHHS will not require documentation for self‑attested conditions.
  • In 2028, federal rules will require documentation. MDHHS will share more information in 2027.

 

Healthcare Data Pathway

MDHHS organizes its medical frailty conditions into two groups:
 
Category 1:

Conditions that have been determined to be severe enough to qualify. No additional information is needed.

Category 2:

Conditions that may qualify but require more information to confirm severity. For these conditions, Michigan looks for additional data indicators, like hospital stays or repeated high-intensity outpatient care, to confirm that the person’s health needs rise to the level of medical frailty.
Other situations that qualify:

MDHHS will also automatically exempt individuals who have spent 30 days or more in any of the following:

  • A general hospital
  • Hospice
  • A nursing facility
  • A state psychiatric hospital
  • A psychiatric residential treatment facility

or who are enrolled in:

  • Program of All-Inclusive Care for the Elderly (PACE)
  • MI Choice Waiver
  • Habilitation Supports Waiver

These situations show that an individual's overall health or support needs make it difficult to meet work requirements.


Category 1 and 2 Code List

 

How the exemption is applied

Once MDHHS identifies a medically frail condition through the healthcare data pathway:

  • The exemption is applied automatically during the application and renewal.
  • No action is needed from the beneficiary.
  • The exemption remains in place for 12 months and is updated if newer information becomes available.