Medically Frail Guidance
CMS Definition of Medically Frail
The Centers for Medicare & Medicaid Services (CMS) defined medically frail as follows 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
The Montana Department of Public Health and Human Services (DPHHS), led by the Department’s State Medical Officer, developed the following approach. Please note that DPHHS still expects additional guidance and clarification from CMS regarding medically frail. This approach will be updated as needed by the Department.
Verifying Medically Frail Status
DPHHS accepts provider documentation or self-declaration to verify medically frail status at both application (optional) and redetermination. The self-declaration form is included on Page 4 of Appendix B: Community Engagement Exclusion Form.
Earlier communications from the Department stated that self-declaration was only allowable at application; however, new guidance from CMS has shifted the Department’s approach, and self-declaration is allowable at both application and redetermination. The Department is currently developing an interface that will connect with existing medical claims data to evaluate medically frail status for existing and some former clients. This interface will launch in the fall. More information about this change and ways to request an exclusion for a condition not included in Montana’s existing medically frail framework will be communicated at that time.
Conditions that Qualify as Medically Frail
| Description | Medically Frail Category |
|---|---|
| Adult failure to thrive | Disabling Mental Disorder |
| Age-related debility | Disabling Mental Disorder |
| Alcohol use disorder | Substance Use Disorder |
| Alcoholic hepatic disease/cirrhosis | Serious or Complex Medical Condition |
| Amputation — acquired absence of limb (upper/lower extremity, various levels) | Physical, Intellectual, or Developmental Disability |
| Amyotrophic lateral sclerosis (ALS) | Serious or Complex Medical Condition |
| Bed confinement; need for assistance; limited mobility | Physical, Intellectual, or Developmental Disability |
| Brain injury — traumatic intracranial injury (acute, initial encounter) | Physical, Intellectual, or Developmental Disability |
| Brain injury sequelae — personality/behavioral disorders due to known physiological condition | Physical, Intellectual, or Developmental Disability |
| Cancer | Serious or Complex Medical Condition |
| Cerebral palsy (spastic, dyskinetic, ataxic, mixed, unspecified) | Physical, Intellectual, or Developmental Disability |
| Chronic Kidney Disease stage 5 or ESRD | Serious or Complex Medical Condition |
| Chronic obstructive pulmonary disease (COPD) | Serious or Complex Medical Condition |
| Cognitive impairment — mild neurocognitive disorder due to known physiological condition | Disabling Mental Disorder |
| Creutzfeldt-Jakob disease | Serious or Complex Medical Condition |
| Cystic fibrosis (pulmonary manifestations, meconium ileus, other complications) | Serious or Complex Medical Condition |
| Delusional disorders | Disabling Mental Disorder |
| Dementia (vascular, Alzheimer's, other) | Disabling Mental Disorder |
| Dependence on ventilator, wheelchair, oxygen, other devices | Physical, Intellectual, or Developmental Disability |
| Down syndrome (trisomy 21 nonmosaicism, mosaicism, translocation) | Physical, Intellectual, or Developmental Disability |
| Emphysema | Serious or Complex Medical Condition |
| Fragile X syndrome | Physical, Intellectual, or Developmental Disability |
| Gait and mobility issues | Physical, Intellectual, or Developmental Disability |
| Heart disease — ischemic heart disease (angina, MI, chronic ischemic, other) | Serious or Complex Medical Condition |
| Heart failure; hypertensive heart/CKD | Serious or Complex Medical Condition |
| Hemophilia (A, B, C) and other hereditary coagulation defects | Serious or Complex Medical Condition |
| History of falling | Physical, Intellectual, or Developmental Disability |
| HIV/AIDS — human immunodeficiency virus disease | Serious or Complex Medical Condition |
| Huntington's disease | Serious or Complex Medical Condition |
| Major depressive disorder | Disabling Mental Disorder |
| Multiple sclerosis | Serious or Complex Medical Condition |
| Muscle atrophy, weakness, sarcopenia | Physical, Intellectual, or Developmental Disability |
| Muscular dystrophy (Duchenne, Becker, limb-girdle, facioscapulohumeral, other) | Physical, Intellectual, or Developmental Disability |
| Opioid use disorder | Substance Use Disorder |
| Other non-mood psychotic disorders (brief psychotic, shared psychotic, other) | Disabling Mental Disorder |
| Panic disorder | Disabling Mental Disorder |
| Parkinson's disease | Serious or Complex Medical Condition |
| Prader-Willi syndrome | Physical, Intellectual, or Developmental Disability |
| Pressure ulcers | Physical, Intellectual, or Developmental Disability |
| Pulmonary fibrosis | Serious or Complex Medical Condition |
| Respiratory failure | Serious or Complex Medical Condition |
| Sarcoidosis (pulmonary, lymph nodes, skin, other and combined organs) | Serious or Complex Medical Condition |
| Schizophrenia (paranoid, disorganized, catatonic, undifferentiated, residual, other) | Disabling Mental Disorder |
| Schizotypal disorder | Disabling Mental Disorder |
| Sickle cell disease (Hb-SS, Hb-SC, sickle-cell thalassemia, and other types) | Serious or Complex Medical Condition |
| Spina bifida (cervical, thoracic, lumbar, sacral; with/without hydrocephalus) | Physical, Intellectual, or Developmental Disability |
| Spinal cord injury sequelae — paraplegia, quadriplegia, other paralytic syndromes | Physical, Intellectual, or Developmental Disability |
| Spinocerebellar ataxias (early-onset, late-onset, X-linked, other hereditary) | Serious or Complex Medical Condition |
| Stimulant use disorder | Substance Use Disorder |
| Thalassemia major (beta thalassemia / Cooley's anemia) | Serious or Complex Medical Condition |
| Trauma disorders — PTSD, acute stress reaction, adjustment disorders | Disabling Mental Disorder |
| Viral hepatitis (chronic hepatitis B, C, and other chronic viral hepatitis) | Serious or Complex Medical Condition |
| Weakness, malaise, fatigue | Physical, Intellectual, or Developmental Disability |
| Weight loss, underweight, cachexia | Disabling Mental Disorder |