Eric Levine, M.P.H., on Medicaid work requirement exemptions and ADLs

A new CMS interim final rule narrows the medical frailty exemption from Medicaid’s incoming work requirements, requiring enrollees to show not just a diagnosis but also an impairment in at least one activity of daily living (ADL), according to Eric Levine, M.P.H., principal at Avalere Health.

CMS released the rule June 1. It applies to the roughly 20 million people who became eligible for Medicaid through the Affordable Care Act’s state-by-state expansions and takes effect in 2027. To keep coverage, most people in that population will need to document 80 hours a month of employment, community service or job training, unless they qualify for an exemption such as medical frailty.

In an interview with Managed Healthcare Executive (MHE), Levine explained that having a medical condition won’t be enough to qualify for an exemption. A diagnosis of autism, for example, is not by itself sufficient to be exempted under the new rule. An enrollee would also need to show the condition affects an ADL, such as bathing, dressing or eating unassisted. However, some conditions, such as blindness, don’t have the ADL impairment requirement, Levine explained. Further complicating matters is that states will have some digression over which medical conditions to list as qualifying people for exemptions.

In this video, Levine tells MHE that the added documentation burden isn’t intended to fall on Medicaid members themselves. States are supposed to verify eligibility on their own using existing data sources, he said, but states that can’t obtain the data they need may end up asking members directly to prove the severity of their condition.

Levine wrote about Medicaid work requirements on the Avalere Health website. In that piece, he argues that the rule creates a new role for life science companies, health plans and providers in helping members document their conditions and understand the new requirements.