How states can determine medical frailty under H.R. 1 using clinical criteria

As 42 states and Washington, D.C. prepare for new work and community engagement requirements under H.R. 1, one question rises to the top: How should states consistently and fairly determine who qualifies as medically frail?

The medically frail exemption is essential for protecting people with complex health needs, but it also introduces operational complexity. With federal expectations for auditability and consistency, states need methods that are clinically grounded, transparent, and based on verifiable data.

This is where clinical, categorical risk adjustment can help.
 

Understanding the challenge ahead

This year, 42 states and Washington, D.C. are preparing to implement the medically frail exemption outlined in H.R. 1. A recent KFF Health News article described one of the most difficult elements: identifying individuals who fall into the “serious or complex medical condition” category — a definition that varies in interpretation and application.

As the article noted:

“The law spells out certain ‘medically frail’ conditions such as blindness, disability, and substance use disorder. But it does not list many others. Instead, the law exempts those with a ‘serious or complex medical condition,’ a term whose interpretation could vary by state.”

The existing regulatory definition under 42 CFR 440.315 provides some structure, outlining medically frail individuals as those who have:

• A disabling mental disorder
• A chronic substance use disorder
• A serious and complex medical condition
• A physical or developmental disability that significantly impairs daily activities
• A disability determination made by the Social Security Administration (SSA)

The Centers for Medicare & Medicaid Services has emphasized that states must use an auditable, data‑backed approach to verifying medical frailty. While SSA determinations are straightforward, other categories — especially “serious and complex medical conditions” — leave more room for interpretation.
 

Why a clinically grounded approach matters

Identifying medical frailty requires more than a simple checklist. States need approaches that are:

• Consistent across diverse populations
• Based on verifiable medical data
• Aligned with federal expectations
• Operationally scalable for health plans and agencies
• Fair, transparent and equitable for members

Using structured clinical methodologies — such as categorical risk‑adjustment models, diagnosis‑based classification systems and functional status groupings — can help states meet these needs. These tools draw on standardized claims, encounter data and historical diagnostic codes to create a uniform way to classify clinical complexity and chronicity.
 

How clinical classification models support medical frailty determinations

Clinical classification models offer an objective way to understand an individual’s clinical complexity, chronic condition burden, and expected care needs. These models sort individuals into categories based on:

• Severity of illness
• Number and type of chronic conditions
• Functional limitations
• Persistence of disease over time

This structured approach helps states design clear, repeatable data‑driven criteria for determining medical frailty under H.R. 1.

• Benefits of clinical classification and risk adjustment approaches
• Audit‑ready documentation grounded in diagnosis codes
• Reduced reliance on burdensome provider attestations or member self‑report
• Consistency across plans, counties and case reviewers
• Transparent criteria that protect individuals with significant health needs

These models also support broader Medicaid priorities like identifying high‑need members, forecasting resource demand, and informing care coordination strategies.
 

Applying clinical criteria across the medically frail categories

Here’s an example of how structured clinical classifications can map to federal categories.
 

1. Disabling mental disorder

Models can identify members with:

• Schizophrenia spectrum disorders
• Bipolar disorders
• Severe depressive or psychotic disorders

States may optionally include moderate but persistent mental health conditions based on policy choices and population needs.
 

2. Chronic substance use disorder

Classifications can flag individuals with:

• Chronic alcohol dependence
• Opioid, cocaine, or stimulant dependence
• Other significant substance use disorders

These determinations rely on diagnosis codes and historical service patterns rather than subjective assessment.
 

3. Serious and complex medical condition

Many states and health systems have used criteria similar to:

• Multiple dominant chronic conditions
• High‑severity classifications
• Multisystem disease involvement

These criteria capture individuals whose health needs meaningfully limit their ability to work or engage in community activities.
 

4. Physical or developmental disability impacting daily activities

Models may include:

• Developmental disabilities
• Neurological or congenital conditions
• Functional status scoring systems that reflect limitations in activities of daily living

Using a combination of diagnostic classifications and functional scoring creates a more complete picture of an individual’s daily living challenges.
 

Beyond eligibility: Improving outcomes for exempt and non‑exempt populations

Data‑driven clinical classification frameworks don’t stop at determining eligibility. They also help states:

• Track chronic disease progression
• Measure treatment effectiveness
• Design targeted care management programs
• Predict potentially avoidable clinical events
• Protect resources for those who need them most

By grounding decisions in standardized data, states can improve member safety, reduce preventable costs, and ensure that medically frail individuals receive the support and protection intended under H.R. 1.
 

Solving what matters, even in complex policy environments

Healthcare work is rarely simple. But when states use clear, clinically derived and verifiable methods, they gain a consistent and compassionate way to identify individuals with serious and complex needs. This helps ensure that medically frail populations are not just protected under the law — but supported in a way that honors their health challenges and promotes better outcomes.

Megan Carr is vice president of regulatory and payer solutions at Solventum.

Lisa Turner is a clinical development specialist at Solventum.