Identifying the medically frail key to future Medicaid expansion, UMass Medical School expert says

June 26, 2017

Federal regulations on the treatment of the “medically frail” could in fact provide an “opportunity” for states which seek to expand their Medicaid programs in the future, notes Sherry Campanelli, MPA, disability evaluation expert at UMass Medical School.

“For states who are considering expansion… medical frailty may offer an opportunity for them to choose alternative benefit plans for their expansion population while at the same time assuring that the most medically needy population has access to full, state-plan Medicaid,” 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 that accept money under the Affordable Care Act (ACA) to expand Medicaid have the option of forming more flexible and potentially cost effective “alternative benefit plans” to cover many of their new enrollees.

But in order to do so, they must first be able to identify the medically frail. Federal regulations say that this population can choose to be enrolled in the core, “state plan Medicaid” or alternative benefit plan.

The medically frail are individuals with serious mental and physical disabilities, children with emotional problems or in foster care, and those with chronic substance abuse problems, among others.

As a result, states that develop their own systems for identifying the medically frail can enroll their sicker and older population in their traditional Medicaid program while creating a separate, alternative plan for other new enrollees, says Campanelli, who provides guidance to states looking to improve their Medicaid disability determination process.

States that have already taken this path use a variety of methods for identifying the medically frail, including self-identification, review of claims data, risk assessment and underwriting analysis.

Still, Campanelli also acknowledges the uncertainty surrounding the debate in Washington, D.C., over the future of the nation’s health care system has made it difficult for states to plan for the future.

Senate Republicans are reworking a House bill that would repeal key parts of the Affordable Care Act and wind down the expansion of Medicaid. It’s not clear yet whether the emerging Senate proposal might preserve some form of Medicaid expansion or simply delay its demise.

To date, 31 states and the District of Columbia have expanded their Medicaid programs with money from the ACA while North Carolina is considering doing so. Eighteen states have opted not to expand Medicaid, though a number seriously debated whether to do so.

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