Understanding CMS's New Implementation Guidance for Medical Frailty
Establishing a two-tiered system for medical frailty in June’s Interim Final Rule
In June 2026, CMS introduced an Interim Final Rule for a two-tiered approach to establishing medical frailty. This approach significantly deviated from past precedent, which had broad state discretion, allowing for self-attestation and provider documentation.
The June 2026 Interim Final Rule established:
- Previously Established: the individual falls into one of five statutory categories (blind or disabled, substance use disorder, disabling mental disorder, a disability significantly impairing an activity of daily living, or a serious/complex medical condition), AND:
- New as of June 2026: the condition significantly impairs their ability to comply with community engagement.
September’s additional three-tiered implementation guidance
CMS shared states DO have significant flexibility in deciding which medical conditions qualify as serious/complex and how they apply this tiering system.
States determine which combinations of conditions using ICD-10 codes and supporting data qualify for HR1 exemptions, using CMS’s 3-tiered system. CMS gives additional flexibility for states to define set combinations of ICD-10 codes and supporting data to establish their own exclusion methodology.
- Tier 1: Specific ICD-10 diagnostic codes qualify for automatic HR1 exclusions → states will have discretion to decide which ICD-10 codes qualify.
- CMS provides examples of pancreatic cancer and ALS
- Tier 2: ICD-10 diagnoses with supporting data.
- Supporting data could mean leveraging different claims databases (e.g., workers' comp, prescriptions, previous insurers, FFS), health records, or provider encounters
- Tier 3: For cases with insufficient data, CMS mandates deeper, individualized review.
- Health records including detailed history with diagnostic testing
- Provider documentation/certification
- MCO plan care management information
- Level of care functional assessment
The takeaway: data-driven approvals
This guidance moves away from doctors' interpretations and self-attestations, and to more discrete, defined outcomes leveraging procedural codes and data as the first source of truth. This shift could significantly streamline approvals once states establish methodologies with ICD-10 codes and supporting data, removing strain from state caseworkers and medical providers.
If states fail to build comprehensive diagnostic systems, especially after self-attestation ends, we could see a significant uptick in manual and time-intensive processes like level of care assessments and detailed provider certifications, delaying coverage and creating inconsistencies across cases.
How Fortuna helps
Fortuna can help members understand what documentation and data might be useful when submitting their applications for medical frailty, even when using self-attestation, so there is clear alignment with the medical frailty rules and guidance for respective state and market.
As states develop exclusion methodologies, Fortuna can help plans incorporate newly established structure into their MCO plan care management to ensure continuity of care for medically frail populations.
