Many people who get health care through programs like Medicaid expansion will have to follow work requirements. The rule says a few kinds of people do not need to follow work requirements. This resource focuses on just people who are medically frail. The definition of medically frail can be confusing. This bad rule made a new definition.

Two things have to be true about a person for the rule to say that person is medically frail:

• The person has to have a disability or a serious health condition. A serious health condition can mean something like HIV/AIDS, cancer, or another health condition. Serious health conditions are disabilities. Sometimes this resource just says “disability.” 

AND 

• Prove they cannot work because of their disability or serious health condition. 

There are many problems with the rule’s definition of “medically frail”. One problem is it does not say every disability that can mean someone is medically frail. The rule gives some examples, but the examples are confusing. We will talk more about these examples in the section of this resource called “What disabilities or health conditions can make someone count as ‘medically frail’?” [LINK SECTION]

Another problem is that the rule does give states enough guidance. The rule does not  tell states how people can prove they cannot work.

States can decide that a disabled person has to work. States can decide this even if the disabled person can not work. This means a state can take away health care from people who can’t work.

Millions of people will lose their health care because of this rule. That is why we wrote a plain language Action Alert [LINK] to show you how to tell CMS to change this bad rule.

How do you know if this rule says you are medically frail?

The rule talks about five kinds of disabilities or health conditions. If you have those disabilities, the rule might say you are medically frail. These disabilities or health conditions are qualifying conditions. Qualifying condition means the rule says you might be medically frail. You are medically frail if you prove you can’t work and you have a qualifying condition.

This section talks about qualifying conditions. The next section talks about proving you can’t work.

The list below is from the CMS rule. The list is about each qualifying condition. We know this language is not accessible. But, your state might use these words when they talk about work requirements. Clicking on each term brings you to a plain language explanation.

• Individuals who meet the SSA definition of Blind or disabled 
• Individuals with significant physical, intellectual, or developmental disabilities that impair their ability to perform at least one Activity of Daily Living
• Individuals with substance use disorders
• Individuals with a disabling mental disorder
• Individuals who have a serious or complex medical condition

People who meet the SSA definition of Blind or disabled 

SSA is short for Social Security Act. The Social Security Act is the big law that creates government programs. Those programs protect people from poverty and make sure people have health care.The SSA says who can get help from some programs. One group of people the SSA talks about is “blind and disabled”. Certain things have to be true about a person for the person to be in the blind and disabled group. The CMS rule says that a person might be medically frail if they are in the blind and disabled group of the SSA.

People who meet the SSA definition of Blind or disabled might have a qualifying condition. But that’s not enough to prove you are medically frail. The CMS rule says you also need to prove you can’t work. We still don’t know how people will prove they can’t work. This is part of why this rule is so bad.

People with significant physical, intellectual, or developmental disabilities that impair their ability to perform at least one Activity of Daily Living

Activities of Daily Living (ADLs) are things that most people do every day to live independently. Many disabled people need help with some ADLs. Some examples of ADLs are 

• Getting dressed
• Brushing your teeth
• Going to the bathroom

The rule says that people with disabilities who struggle with ADLs might be medically frail. Their disability has to be why they have a hard time with ADLs. The disability has to be a physical, intellectual, or developmental disability. 

A physical disability is a condition that affects the way someone can move their body. 

An intellectual disability is a disability that affects someone’s brain. Intellectual disabilities can make it hard for someone to learn. They can also make it hard for someone to do everyday skills. 

A developmental disability is a disability someone is born with. Or, a disability that starts before the age of 22. Developmental disabilities last someone’s whole life. Developmental disabilities can make it hard for someone to learn or take care of themselves. Some kinds of developmental disabilities are autism and Down syndrome.

Developmental disabilities are all qualifying conditions. But that’s not enough to prove you are medically frail. The CMS rule says you also need to prove you can’t work. We still don’t know how people will prove they can’t work. This is part of why this rule is so bad.

People with substance use disorders

A substance is something like drugs or alcohol. Some common drugs are heroin, fentanyl, and cocaine. CMS does not exactly say what a substance use disorder is. CMS does give examples of what substance use disorder could be. The CMS rule says you might have a substance use disorder if:

• A doctor says you have substance use disorder
• You keep using drugs or drinking alcohol even though it hurts your body and brain 

People with substance use disorders might need help to stop using too many substances. This is so substances stop hurting their body or brain.

People with substance use disorder can also be in active treatment or recovery. Active treatment is when someone with a substance use disorder gets help to stop using substances. Recovery is when someone stops using substances in a way that hurts them.

People with substance use disorders might be medically frail. The rule says that people with substance use disorders might have a qualifying condition. People with substance use disorders do not have to be getting active treatment to have a qualifying condition. The rule says that people who have been in recovery for at least 5 years do not have a qualifying condition.

Substance use disorder can be a qualifying condition. But that’s not enough to prove you are medically frail. 

The CMS rule says you also need to prove you can’t work. We still don’t know how people will prove they can’t work. This is part of why this rule is so bad.

People with a disabling mental disorder

The rule is confusing. It is not easy to understand what CMS says  a “disabling mental disorder” is. Some kinds of mental health disabilities are disabling mental disorders. The rule gives some examples of mental health disabilities that might be disabling mental disorders. 

The examples the rule gives are 

• Schizophrenia
• Schizotypal disorder
• Delusional disorder
• Other non-mood psychotic disorders
• Moderate or severe bipolar disorder
• Major depressive disorder
• Panic disorder

If someone has one of these conditions, that person might have a qualifying condition. But having a qualifying condition is not the only thing that makes someone medically frail. The CMS rule says you also need to prove you can’t work. We still don’t know how people will prove they can’t work. This is part of why this rule is so bad.

Individuals who have a serious or complex medical condition

The rule is not easy to understand. The rule is confusing about what a serious or complex medical condition is. 

Rules in the past have been easier to understand. Past rules say a serious or complex medical condition is something that could kill or really hurt someone. And that this could happen if the person does not get the health care they need. 

For example, Josie has a medical condition. They use a machine to help them breathe. If Josie loses this machine, they could die. Some rules say that means Josie has a serious or complex medical condition.

This rule says something different. This rule also says a serious or complex medical condition is something that could kill or really hurt someone. 

The difference is about treatment. Other rules said you still have a serious or complex medical condition if treatment keeps you healthy. This rule says that if treatment keeps you from not dying, then you don’t have a serious or complex medical condition. 

Rules in the past said Josie has a serious or complex medical condition. That is because they need a machine to help them breathe. Because of the machine, Josie is not at risk of dying. 

This new rule says Josie does not have a serious or complex medical condition. The CMS rule says that because they are not at risk of dying with the machine.

The CMS rule does say some people have a serious or complex medical condition. Some people might die even when they have the healthcare they need. The rule says those people have a serious or complex medical condition.

This is bad for people who have these disabilities. This rule means that people who are too sick or disabled to follow work requirements will lose their health care. That means people with disabilities losing the treatment that keeps them alive. This is part of why this rule is so bad.

Having a qualifying condition is not the only thing that makes someone medically frail. The CMS rule says you also need to prove you can’t work. We still don’t know how people will prove they can’t work. This is part of why this rule is so bad.

What does the rule say about people who can’t work? How can someone prove their qualifying condition makes them not able to work?

The CMS rule is not easy to understand.  The rule does not say how people can prove their qualifying condition makes them not able to work.

The rule says that states have to decide who has to follow work requirements. The rules say states need to use data for this. Another word for data is information. The data they use is about people who get health care through Medicaid. The data is also about people who are trying to get health care through Medicaid. 

States already have to get some kinds of data. States already have data about some people’s qualifying conditions. But states do not have a way to get all the data CMS wants them to have. States do not have a way to get data that says someone’s disability means they can’t work. That data does not exist. 

This means states might have to ask people questions about their disability. The questions will help states get data that says someone’s disability means they can’t work. The rule does not say what questions states have to ask. The rule does not tell states how to get the data. People might have to do a lot of paperwork to help states get the data. That is not fair to people who get health care through Medicaid. People who get health care through Medicaid already have to fill out a lot of paperwork.  

A lot of people could lose their health care. This is because many people do not have the support they need to fill out all the paperwork. 

The rule does not make it clear how people can prove they can’t work. The rule does not make it clear how people can prove a qualifying condition makes them not able to work. 

Millions of people will lose their health care because of this bad, unclear rule.