Who Counts As Medically Frail

Federal law treats five groups of people as medically frail, and each state turns those groups into its own list of qualifying conditions.

Blind Or Disabled

As defined in section 1614 of the Social Security Act.

Substance Use Disorder

Unless the person has been in stable recovery for five years or more.

Disabling Mental Disorder

A mental health condition that is disabling.

Physical, Intellectual Or Developmental Disability

One that significantly limits at least one activity of daily living.

Serious Or Complex Medical Condition

One that is life-threatening, seriously disabling, causes significant pain or needs frequent monitoring, among other descriptors in the rule.

Your State's Condition List

Every state must keep a written list of the diseases, diagnoses and conditions that qualify. CMS requires the list to be auditable and justifiable, and states must revise it regularly to add or remove conditions.

Conditions Not On The List

Members whose condition isn't listed must have a reasonable way to request that the state consider it.