INDIANA — Indiana health officials have revealed how the state plans to define and enforce an updated “medical frailty” exemption ahead of new work requirements set to take effect for Medicaid expansion enrollees on January 1.
Under the new guidelines, roughly 355,000 working-age adults enrolled in the Healthy Indiana Plan (HIP) must complete 80 hours per month of work, volunteering, or education—or earn at least $580 monthly—for three consecutive months to maintain coverage.
To protect vulnerable individuals, the Indiana Family and Social Services Administration (FSSA) is adopting a narrowed federal definition of medical frailty to serve as a primary exemption.
New Federal Standards for Exemption
Under the new framework, enrollees qualify as medically frail if they fit into one of five designated categories—such as physical or mental disabilities, severe mental illness, substance use disorders, or complex medical conditions—and if their health condition significantly limits their ability to fulfill the monthly 80-hour requirement.
Exemptions granted under the medical frailty designation will remain valid for six months at a time.
A Three-Tiered Evaluation System
The state will utilize a new automated claims-screening program called Milliman Advanced Risk Adjusters (MARA) alongside clinical reviews to determine eligibility across three tiers:
- Tier 1 (Diagnosis-Based): Automated identification of members carrying specific diagnoses on an established state health list.
- Tier 2 (Evidence-Based): Automated evaluation reviewing qualifying conditions in tandem with active treatments, services, or support claims.
- Tier 3 (Clinical Review): A manual referral process where enrollees, providers, or managed care entities can submit supplemental medical records, lab results, and physician notes directly to state clinical staff for review.
Initial state estimates run in late September indicate nearly 140,000 HIP expansion members will automatically qualify for the medical frailty exemption through the automated screening tool.
Additional exemptions remain available for parents of young children, individuals participating in select addiction treatment programs, and other exempt populations.
