Medically Frail Guidance

CMS Definition of Medically Frail

The Centers for Medicare & Medicaid Services (CMS) defined medically frail in the Interim Final Rule with Comment (IFC) released on June 1, 2026:

We are defining a medically frail individual at § 435.554(c)(5) as an individual whose physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement in this subpart and who is blind or disabled (as defined at section 1614 of the Act); with a substance use disorder (SUD); with a disabling mental disorder; with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living (ADLs); or with a serious or complex medical condition. Individuals only need to fit within one of these categories to qualify for the medically frail exclusion to the community engagement requirement. ^[1]

^[1] Federal Register: Medicaid Program; Community Engagement Requirement for Certain Individuals; Interim Final Rule with Comment Period

In the IFC, CMS provides some guardrails and suggestions around the five categories of medically frail, but did not provide specific definitions for substance use disorder, disabling mental disorder, physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living (ADLs), and with a serious or complex medical condition. For plain language communications, the Department refers to medically frail as “a medical condition or health needs that impact ability to work or do other community engagement activities.”

Montana’s Approach to Medically Frail

Led by our State Medical Officer, DPHHS has developed a Medically Frail Condition List that includes ICD-10 codes that meet the CMS criteria for Medically Frail and reliably indicate that an individual is not able to work or otherwise meet the community engagement requirement. This list was developed in alignment with the IFC and recent guidance from the National Association of Medicaid Directors (NAMD) on medically frail frameworks for states to consider. Individuals with one or more of these conditions qualify for the medically frail specified exclusion and are excluded from the community engagement requirement. More information about the Medically Frail Condition List is provided below.

Starting October 1, 2026, DPHHS will begin using Medicaid claims data to automatically identify individuals who qualify for this exclusion. The Department’s CHIMES eligibility system will check an individual’s claims history over the last twelve months for diagnosis codes that match the Medically Frail Condition List.

Medically Frail Condition List

1. Tier 1 Conditions: Conditions that align to the five CMS categories of medically frail and reliably indicate that an individual cannot work or otherwise meet the community engagement requirement
2. Tier 2 Conditions: Frailty indicators that reliably indicate that an individual cannot work or otherwise meet the community engagement requirement

If an individual’s claims include a code from either tier, they will be excluded from the community engagement requirement due to their medically frail status.

This condition list will continue to evolve as the Department reviews medically frail data and monitors community engagement implementation. As stated in § 435.554(a)(5)(ii)(B): “the state must revise this list on a regular basis to add or remove diseases, diagnoses, disorders, or health conditions based on the State's experience applying this exclusion.” Any future revisions to this list will be posted on this page.

Verifying Medically Frail Status

The steps below detail the process for verifying medically frail status after October 1, 2026. Please note that the Department checks for all specified exclusions and mandatory exceptions in an established sequence: once an individual is confirmed to meet an exclusion or exception, further exclusions or exceptions may not be verified.

1. Check Against Existing Medicaid Claims to Verify Medically Frail Status
   1. For both applicants and existing clients, the Department will first automatically review medical claims history for a condition on the Medically Frail Condition List. This will occur as part of the ex parte, or autorenewal, process for existing clients, and upon initial application review for new applicants. In these initial data checks, the Department will first check for specified exclusions (including medically frail via claims check), mandatory exceptions, or qualified activities that can be identified using existing data without the client needing to submit additional documentation. 
      1. If the Medicaid claims check is successful (i.e., the individual has at least one Medicaid claim with a matching code from the DPHHS Medically Frail Condition List in the past twelve months), then the individual will automatically be granted a medically frail specified exclusion from the community engagement requirement. This individual will not receive a notice of non-compliance or be asked to provide additional information to verify their compliance with the community engagement requirement.

      2. If the Medicaid claims check is unsuccessful, new applicants and existing clients will need to provide other documentation of their medically frail status. Some reasons the Medicaid claims check can be unsuccessful include no claims present, claims present but outside of the established window, inaccurate coding, or delays in claim submission.

2. Provide Other Documentation to Verify Medically Frail Status

   1. The Department understands that there may be individuals who have a condition on the Medically Frail Condition List but do not have Medicaid claims present. In this case, the individual may submit documentation to show that they qualify for the Medically Frail specified exclusion.

      1. Existing Clients may submit a provider attestation of their medically frail status. Clients may use the Provider Attestation Form, included in Appendix B with their redetermination packet, to verify their medically frail status in collaboration with their provider.

      2. New Applicants may submit a self-declaration of their medically frail status using the Self-Declaration form in Appendix B, mailed with their notice of non-compliance.

3. Request an Exception to the Department’s Medically Frail Condition List
   1. At § 435.554(a)(5)(ii)(C), the CMS IFC states that “if an individual does not have a disease, diagnosis, disorder, or health condition on this list, the State must have reasonable processes and criteria in place for such individual to request consideration for the exclusion”.
   2. The Department has created a Medically Frail Condition Request Form to allow individuals to request approval of medically frail status based on a condition that is not currently included on the Department’s Medically Frail Condition List. Individuals should work with their providers to complete this form and submit to DPHHS for review.
   3. Please note that Medically Frail Condition Request Forms may only be reviewed for individuals who would be a specified excluded individual solely due to their medically frail status (e.g., medically frail is the only specified exclusion that would apply to them).

If I have a history of substance abuse, do I qualify for the medically frail exclusion or the participating in an alcohol or drug addiction treatment program​?

Individuals with a history of substance use may be excluded from the community engagement requirement under one of the following two categories:​

• Medically Frail
  • An individual qualifies for a medically frail exclusion if they have a SUD diagnosis that is included in Montana’s approved list of conditions at time of application/redetermination​. For more information, see the Medically Frail Guidance.
  • This does not include individuals in stable recovery (5 or more years).
• Participating in an alcohol or drug addiction treatment program
  • An individual qualifies for an exclusion based on participation in a drug or alcohol treatment program if they are in a treatment program that includes one or more services at or above ASAM Level 2.1 at the time of their application or redetermination. This includes intensive outpatient services and clinically or medically managed inpatient services. Speak with your provider if you have questions about what types of services qualify for this exclusion. 
  • Any Medicaid-enrolled provider at a private non-profit organization or institution or any publicly-operated community mental health center that provides clinical services at ASAM Level 2.1 or above.​

An individual may qualify for both of these exclusions. This does not impact eligibility. DPHHS has a verification matrix that shows what proof is needed for these exclusions.

Please reference the verification matrix for additional information.