Medical Frailty Rule Challenged in Second Lawsuit
Since the Medicaid Work Requirement rules were released in June, there has been a wave of public opposition to the restricted definition of “medical frailty” they introduced, which poses a number of legal problems. Under a typical medical frailty exemption, many people with disabilities should be allowed to retain their Medicaid coverage without completing the additional 80 hours per month of work and community engagement activities being implemented in January 2027. As we’ve previously reported, the medical frailty exemption now dangerously mandates that medically frail individuals are required to also prove their inability to work to receive the exemption. Providing the documentation needed to regularly prove an inability to work could be a barrier to the stable health coverage that people need to maintain their health and supportive services like home care.
Disability and public health advocates have called for the retraction of these medical frailty rules. The same month that these new Medicaid rules were released, a coalition of 24 states, along with the District of Columbia and two Governors, filed a lawsuit challenging them. They emphasized the unprecedented and unexpected nature of the medical frailty rule. Initial guidance to states had indicated that some people would be exempt from work requirements based on their disability or health status. With that in mind, many states were looking at ways to streamline the exemption process based on existing diagnostic criteria to make the exemption process easier to manage. The additional medical frailty exemption rules presented an administrative burden for states, on top of the new work requirements themselves. The rules also created a risk for people with complex health needs and put their coverage at risk of termination. This first lawsuit is still pending. You can follow the progress of that case through the Milken Institute of Public Health at George Washington University.
Now we are just about three months out from when states will be required to launch their work requirements nationally. This past week, a new coalition has filed a second lawsuit focused on the “medical frailty” rules under the current work requirements. One of the organizations that filed the lawsuit was the National Health Law Program (NHeLP). They have released a set of resources explaining the new case, including a case explainer and press release. They outline the harms of the medical frailty rules, from individual Medicaid recipients to health care providers, and local communities:
“First, the IFR [or Medicaid Interim Final Rule] will harm all medically frail individuals, and more medically frail individuals will lose Medicaid than anticipated by Congress. This includes people with diabetes, HIV, SUDs and other behavioral health conditions, and cancer who need ongoing medical care to maintain their health, prevent deteriorating health conditions and relapses, and avoid catastrophic medical debts.
Second, the IFR will harm Medicaid-participating health providers. The IFR requires them to shoulder additional responsibilities to evaluate and document whether Medicaid applicants and enrollees can work, decisions which are decidedly not medical in nature. Further, they will not be compensated for this time-consuming process even though the additional time required will interfere with their efforts to provide medical care.
Third, cities and localities provide a range of health services including public health and emergency services. When they provide services to those who lose Medicaid coverage, they cannot receive Medicaid reimbursement. Because the IFR will create higher coverage losses than anticipated by Congress, cities, localities and locally funded health care providers will face higher uncompensated care costs and reduced revenue.”
These new work requirements are just some of the restrictions limiting access to care through Medicaid since the passage of HR1. Health Affairs has outlined the impact that this is having on documented immigrant communities, with loss of coverage, which will ultimately impact many immigrants with disabilities as well. According to Colorado Medicaid Director, Adela Flores-Brennan: “There is a significant subset of folks who are going to lose coverage who have home and community-based services, institutional levels of care, or are on a buy-in program”. Starting October 1st, the following groups will be among those that are no longer eligible for Medicaid coverage:
- Refugees
- Asylum seekers
- People granted humanitarian parole
- Survivors of domestic abuse with applications under the Violence Against Women Act
- Survivors of human trafficking
- Members of U.S. federally recognized Native American tribes
Please note that immigrants who are pregnant (or recently pregnant), children under 18, and green card holders who fulfilled the five-year waiting program are still eligible for Medicaid. In some states, like Colorado, insurers are reportedly developing Marketplace options to serve low-income individuals, which might be an option for immigrants losing coverage, though plans that had formerly been subsidized through enhanced premium tax credits are no longer an option. Formerly state-funded coverage options for undocumented immigrants are being impacted by the reduced federal Medicaid dollars, as states struggle to provide care for all who need it.
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