The state unveiled its new definition of medical frailty this week, something health care officials have been waiting to see.
The definition helps determine who will be exempt from federal work requirements set to begin in January.
State officials say that their definition could exempt some 140,000 people in Indiana from upcoming work requirements due to medical conditions, including blindness or a disabling mental condition.
Enrollees who are not exempt will need to work 80 hours a month in order to qualify for Medicaid. Those requirements can be met with work, education, or volunteering.
The category of medical frailty was recently changed at the federal level, offering a much narrower exemption that only applies to those who would actively be unable to work because of their health status.
Indiana’s own definition was also changed, and the state has delayed releasing guidance while it worked to clarify how those definitions would ultimately impact members.
Medicaid Chief Clinical Officer Katrina Etter presented the state’s three-tiered tool for determining whether people would qualify on Tuesday during a quarterly meeting of the Family and Social Services Administration. If a member has a tier one diagnosis that might automatically qualify them for an exemption, that is identified from a state list.
That tier one group includes things like substance use disorder, cerebral palsy, or blind and disabled persons.
After that, the state’s tier two qualifications will include both conditions and evidence of ongoing treatments or medication that might serve to identify them as medically frail. A final group, tier three, needs to be reviewed by state staff and submitted by a managed care organization.
“So, for example, you could have a member with depression,” Etter explained. “They would not qualify based on diagnosis alone, but if they had evidence of treatment in a setting that would indicate a severity that could be functionally limiting, they would qualify through that tier two pathway.”
Based on the state’s estimates of how many enrollees are currently meeting the work requirements or qualify for other exemptions, roughly 54,000 people are in danger of losing coverage for not meeting upcoming work requirements.
That new estimate is slightly down from the state’s initial 58,000 estimate earlier this year.
FSSA Secretary Mitch Roob urged healthcare groups to work with members to help them keep their coverage.
“We didn’t create the Healthy Indiana Plan to kick people off,” he said. “We created it because we believed there was a need in the community.”
But some health advocates are worried that the state’s new definition of medical frailty leaves people living with HIV off the list of tier one diagnoses.
Alan Witchey, CEO of the Damien Center, said many people living with the condition rely on Medicaid to help them afford their medication.
“The reason why that's important is that people living with HIV are on medications,” he said. “If you stop taking your medications, your health will dramatically or can dramatically change.”
Witchey and others had been asking the state for clarity on how it would ultimately define medical frailty. He said the state’s plan presents a policy paradox.
“Waiting until a person experiences significant functional impairment, opportunistic illness, or other complications before protecting access to care is inconsistent with the fundamental purpose of HIV treatment: preventing disease progression in the first place,” Witchey said.
A spokesperson for the state, when reached for comment, said people living with HIV could ultimately qualify but would need to provide proof.
Indiana’s work requirements officially take effect on Jan. 1.
Contact Government Reporter Benjamin Thorp at bthorp@wfyi.org
