What Does ‘Medically-Frail’ Mean? Kentucky Medicaid Official Offers Clues

Nov 8, 2017

The insurance program that provides health insurance to almost a third of Kentuckians — Medicaid — will soon change. Kentucky Governor Matt Bevin is awaiting approval from the federal government on his proposed reforms. But even if Bevin gets everything he asked for, Medicaid providers and advocates say there are still a lot of unknowns to how Kentucky will manage the program.

In Kentucky, Medicaid used to just cover pregnant women, children or people who were disabled or living in poverty. Under President Barack Obama’s Affordable Care Act, former Governor Steve Beshear expanded the insurance program to include people living outside of poverty – up to about $33,000 a year for a family of four. The program now covers about a third of Kentuckians, many of whom got on Medicaid through the expansion.

But Bevin has proposed scaling the program back. His plan would establish monthly premium payments and co-pays for people based on income. And it would also require many Medicaid recipients to either work, take GED classes, volunteer, among other things, for 20 hours a week to keep their health coverage. This concept was embraced by the Trump administration on Tuesday.

But  there are groups of people that will be exempt from these payments and work or volunteer requirements: pregnant women, children, caregivers, former foster kids up to age 26 and ‘medically-frail’ people. How the latter will be defined is still unclear.

What Does ‘Medically-Frail’ Mean?

The federal government defines ‘medically-frail’ as people with serious physical, mental, substance abuse or behavioral health conditions.

That’s a pretty big group in Kentucky. For instance, alcohol and drug use treatment services claims increased seven-fold after Medicaid expanded. And nationwide, more than one-third of Medicaid enrollees report having one or more chronic conditions like diabetes.

Jill Hunter, deputy commissioner of the Kentucky Department of Medicaid Services, said her office estimates about 10 percent of Medicaid recipients in Kentucky will get a ‘medically-frail’ designation and be exempt from the premiums, copays and work/volunteer requirement.

Hunter also said there will be a few ways people will be designated medically-frail: through a diagnosis, health insurance claims, or a doctor or the enrollee attesting to the medically-frail status.

“Recipients will be able to attest to it themselves,” Hunter said at the Kentucky Primary Care Association Conference in Lexington on Wednesday. “They’ll be able to fill out a document to say, ‘I encounter these things, whatever the diagnosis may be.’”

“It won’t be folks just sitting in Frankfort trying to make decisions. This will be based on clinical health evaluated appropriately,” she added.

Hunter also said many people’s status will be reevaluated every year.

Though this process might sound cut and dry, one conference attendee who works with the homeless population said many Medicaid enrollees are often hard to track and might not want to go through the designation process. That might apply to people with unmanaged mental health issues or people who are homeless.

Hunter said the state will take other information into account like information from social service agencies on housing status.

“That will be the intent — to take other collateral information that we may have from social service agencies, where we will have to err on the side of the person,” Hunter said.