Medically Frail Determination Framework for Medicaid

This technical report discusses the Milliman Frailty Framework, which is designed to assist state agencies in implementing community engagement requirements under the Budget Reconciliation Act of 2025 (H.R. 1). The report outlines the necessity for accurate, repeatable, and transparent medically frail determinations, particularly as these determinations impact Medicaid eligibility outcomes. It details the various pathways historically used for identifying medically frail individuals, including member health risk screeners, provider certifications, and claims data analysis. The report emphasizes the importance of translating high-level statutory language into specific definitions and operational processes. It also highlights the challenges associated with each determination pathway, such as the administrative burdens of provider assessments and the limitations of relying solely on diagnosis codes. The insights provided are based on experience gained from assisting multiple states in similar implementations, aiming to ensure compliance and effectiveness in identifying medically frail populations.