Medical frailty and Medicaid work requirements: What to know

As states prepare for new Medicaid work requirements under H.R. 1, family physicians are keeping an eye on how patient coverage may be impacted. The AAFP has warned that administrative barriers could cause people to lose Medicaid coverage even when they would otherwise remain eligible.

One particular concern is how CMS is implementing the medical frailty exemption, which is intended to protect patients with significant health challenges. Recent CMS guidance offers gives additional direction on implementing these requirements but does not change the eligibility criteria that the AAFP has flagged as overly restrictive.

Medicaid work requirements are approaching implementation

Under H.R. 1, many adults ages 19 to 64 who are enrolled in Medicaid expansion will be required to complete at least 80 hours of work, education or community engagement every month unless they qualify for an exemption. These requirements take effect Jan. 1, 2027.

States must submit their implementation plans to CMS by Dec. 31, 2026, and fully enact the requirements by the end of 2027. With these deadlines right around the corner, CMS has released outreach materials and guidance to help states prepare. How they put these policies into practice will play a major role in determining how patients maintain coverage, prove eligibility and access exemptions.

What is the medical frailty exemption?

The medical frailty exemption established by H.R. 1 acknowledges that certain Medicaid beneficiaries face health conditions or circumstances that make meeting work requirements unrealistic. It is designed to protect patients whose physical or mental health, disabilities or other serious medical challenges limit their ability to work.

The exemption serves as a critical buffer within the new Medicaid work requirement framework. However, CMS has established additional eligibility criteria that go beyond having the qualifying medical conditions set forth by H.R. 1. This raises questions about how easily patients will be able to access this protection.

Who qualifies for a medical frailty exemption?

According to CMS’ criteria, the exemption may apply to beneficiaries who have:

Having one of these conditions does not automatically qualify a patient for the exemption. CMS also requires that beneficiaries demonstrate that the condition significantly limits their ability to meet community engagement requirements, an additional restriction that the AAFP argues goes beyond what H.R. 1 mandated.

Academy advocacy flags Medicaid coverage concerns

In its comment letter, the AAFP raised concerns that CMS’ narrower interpretation of medical frailty could weaken the exemption’s intended impact. Requiring patients to undergo extensive medical record reviews, provide additional documentation and repeatedly verify their eligibility could create unnecessary hoops to jump through.

Most Medicaid beneficiaries who can work already do so, and many others are dealing with health-related restrictions or other legitimate barriers. Adding additional verification requirements could cause patients to lose Medicaid coverage due to administrative red tape rather than an actual failure to work.

The Academy has also cautioned that these changes could place additional strain on family physicians and their care teams. They may be asked to provide medical records, document physical limitations or contribute to repetitive eligibility reviews.

What the AAFP urged CMS to change

The AAFP urged CMS to delay implementation and revise the rule to take a more practical approach. The Academy also urged CMS to direct states to use existing administrative data to establish a case of medical frailty without extra work when possible. Preserving access to these exemptions while avoiding increased administrative burden is essential.

The current state of Medicaid work requirements

CMS recently released a Community Engagement Outreach Materials package​ to help states, health plans, medical professionals and community organizations understand the upcoming work requirements. The agency also issued guidance on implementing the medical frailty exemption​.

The new guidance encourages states to use information already available through eligibility systems and claims data before requesting additional physician documentation. This approach may limit the administrative burden the AAFP and other physician organizations have raised concerns over.

However, the guidance does not change the underlying eligibility criteria. CMS continues to require beneficiaries to demonstrate that their condition significantly impairs their ability to meet community engagement requirements, maintaining the narrower interpretation of medical frailty that the AAFP has challenged.

What family physicians should expect as implementation moves forward

How these changes impact family physicians will depend on how states develop their verification processes. When existing records cannot establish a patient’s eligibility for the medical frailty exemption, physicians may be asked to explain how the condition limits the ability to meet work and community requirements. Exactly what documentation states request—and how often they do so—remains to be seen.

States still need to build eligibility systems, train staff members and establish procedures for reviews and appeals. Several other implementation questions also remain unanswered as deadlines approach.

The AAFP will continue advocating for an exemption process that protects eligible patients from losing coverage while minimizing unnecessary strain on practices. Members can catch all updates through the Academy’s H.R. 1 advocacy page.