Highly anticipated guidance on medical frailty exclusion for new Medicaid work requirements released
On Sept. 8, the Centers for Medicare & Medicaid Services (CMS) released highly anticipated guidance (PDF) regarding the medical frailty exclusion from new Medicaid work and community engagement requirements, which are scheduled to go into effect on Jan. 1, 2027, under Public Law 119-21, the “One Big Beautiful Bill Act.”
Under the law, individuals who are considered medically frail are excluded from the work and community engagement requirements. The statute identifies five categories of medical frailty: those with a serious or complex medical condition, disabling mental disorder, substance use disorder, significant physical, intellectual, or developmental disability, or who are blind or otherwise meet the Social Security Act disability standard.
In a June 3 Interim Final Rule (IFR) (PDF), CMS significantly narrowed this exclusion by imposing a new impairment standard across all five categories. Under the IFR, states are required to assess not only whether someone has a qualifying condition, but also whether that condition “significantly impairs” their ability to comply with the work requirements using claims and encounter data from the preceding 12 months. These provisions received strong pushback (PDF) from the AMA and others for going beyond the statute and adding a new requirement that will be difficult to prove and operationalize, which will likely result in widespread disenrollments of eligible individuals from Medicaid for procedural reasons, additional burden on physicians, and confusion for states.
The new guidance provides states with a three-tiered verification framework for the medical frailty exclusion. Tier 1 includes conditions confirmed to significantly impair the individual’s ability to work. Tier 2 includes conditions which may indicate an individual is medically frail, but requires additional information such as co-morbidities, pharmacy data, or a functional status assessment to determine whether it significantly impairs their ability to work. Tier 3 cases would proceed to individualized review and require additional documentation.
CMS emphasizes that states are not required to use this tiered framework and that “there are a number of data-driven approaches that states could take.” Nevertheless, the guidance provides some helpful operational clarification. Most significantly, CMS confirms that states may use sufficiently specific diagnosis codes—and, for other conditions, combinations of diagnosis, utilization, pharmacy, durable medical equipment, service and other clinical data—to identify individuals as medically frail through an ex parte review. This data-driven approach could reduce the need for beneficiaries and physicians to submit additional documentation, as the AMA urged (PDF) CMS to clarify. However, available data often do not capture functional limitations or demonstrate how a condition affects an individual’s ability to comply with the community engagement requirement. Consequently, many individuals are still likely to require manual review, creating substantial administrative burdens for states and physicians and increasing the risk that eligible individuals will lose coverage because they are unable to obtain or submit sufficient documentation. The guidance also reiterates that individuals whose conditions are not captured by a state’s code list must have a reasonable process to request consideration for the exclusion. Finally, CMS acknowledges that the IFR’s 12-month claims lookback does not align with its definition of “stable recovery” from a substance use disorder as recovery lasting five years or more. CMS states that it anticipates allowing states to use five years of claims and encounter data for this purpose, although the guidance does not formally amend the regulations.
In addition, the AMA filed an amicus brief (PDF) in support of 25 states and the District of Columbia challenging key portions of the June 3 IFR, including the narrowed definition of medical frailty. In late July, a federal court denied the plaintiffs' motion for a preliminary injunction and set an expedited schedule to consider the merits of the case at summary judgment. The district court is expected to rule before the Jan. 1 implementation date. Notably, under the IFR, states may temporarily accept self-attestations of medical frailty, but this flexibility expires at the end of 2027.
Congress introduces AMA-supported resolution to designate National Physician Suicide Awareness Day
A bipartisan collection of members of the House of Representatives joined together to introduce House Resolution 1519 to designate Sept. 17, 2026, as “National Physician Suicide Awareness Day.” Representatives Haley Stevens (D-MI), Brian Fitzpatrick (R-PA), Eleanor Holmes Norton (D-DC), Bonnie Watson Coleman (D-NJ) and Nanette Barragan (D-CA) are hopeful that this House Resolution will help bring to light the need for greater solutions to the ongoing crises of physician burnout, mental health assistance and suicide.
According to H. Res. 1519, roughly 6 in 10 physicians experience increased feelings of anger, tearfulness or anxiety, and more than half of these same respondents felt levels of debilitating stress. In addition, 7 in 10 physicians report stigma surrounding mental health and seeking mental healthcare among physicians.
“Physicians dedicate their lives to caring for others, yet too many are struggling to care for themselves. Workforce shortages, the frustration and lost productivity caused by relentless prior authorization demands, and the financial pressures of running a medical practice are taking a toll on physicians’ mental health,” said AMA President Willie Underwood III, MD, MSc, MPH. “At the same time, stigma and fear that seeking mental health care could jeopardize a physician’s ability to practice can keep physicians from getting the help they need—and contribute to far too many physician suicides. Recognizing and understanding the realities physicians face is an essential first step. We applaud Reps. Stevens and Fitzpatrick for their bipartisan effort to designate September 17 as National Physician Suicide Awareness Day. The AMA looks forward to working with Congress on meaningful policy solutions to this complex and urgent problem.”
Legislation would help combat childhood diabetes
The AMA sent a letter in support (PDF) of the Childhood Diabetes Reduction Act of 2026 (S. 5026) on Sept. 3. The legislation, which passed out of the Senate Health, Education, Labor and Pensions Committee earlier this summer, would help to address childhood diabetes and other diet-related chronic diseases by increasing awareness of the health risks of sugary drinks, saturated fats, sodium, and processed foods. The legislation would also promote research and public education on nutrition and physical activity while restricting junk food advertising directed at children.
The AMA understands the importance of improving nutrition for patients across the nation and is glad to see this legislation moving in Congress. There is a clear link between poor nutrition and chronic disease. The AMA remains committed to improving American diets, and passing S. 5026 is an important step toward battling chronic disease for our nation's children. The AMA looks forward to continuing to work with the Senate to see this legislation signed into law.
