Options available for states seeking ways to determine “medical frailty,” UMass Medical School expert says

June 20, 2017

States still moving ahead with Medicaid expansion face an added challenge: Setting up systems to identify and properly enroll “medically frail” individuals, notes Sherry Campanelli, MPA, a disability evaluation expert at UMass Medical School.

Newcomers to Medicaid expansion can examine the experiences of other states, which have used a variety of methods to identify this sicker and more vulnerable population, according to Campanelli.

“They can learn from those states by looking at the variety of ways and the results they’ve had in terms of identification of the medical frailty population,” Campanelli says Campanelli, manager of program compliance and appeals at UMass Medical School’s Disability Evaluation Services.

Campanelli’s research on the ways states identify the medically will be presented June 25 at the AcademyHealth Research Meeting.

States who agree to accept federal money under the Affordable Care Act to expand their Medicaid programs are required to form “alternative benefit plans” to cover the new enrollees.

The one exception is for the “medically frail,” individuals with serious mental and physical disabilities, children with emotional problems or in foster care, and those with chronic substance abuse problems, among other issues.

Individuals who qualify as medically frail have the choice of signing up with the new alternative benefit plan created through Medicaid expansion or with the state’s original, core, Medicaid program. Federal health regulators require that the medically frail be able to choose because in some cases the state’s core Medicaid program may provide more generous benefits.

So for states which are expanding their Medicaid coverage, the challenge then becomes sorting out who is medically frail and who is not.

There are a number of different examples states can draw on from across the country in terms of systems for determining medical frailty, according to Campanelli, who provides guidance to states looking to improve their Medicaid disability determination process.

States that have expanded Medicaid are identifying the medically frail by the use of one or more methods, sometimes in combination with each other, she notes. These include self-identification, review of claims data, risk assessment and underwriting analysis.

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