Part 3 2022 Medically Frail

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Part 3
Medically Frail
Alternative Benefit Plans
Protected Classes
Determination of Medically Frail Status

Medically Frail
Medically Frail
Center for Medicare and Medicaid
Services (CMS) has allowed the option of
Alternative Benefit Plans (ABP) that differ
from traditional state Medicaid plans
since 2006.
When a state offers an ABP that is more
restrictive that traditional Medicaid, it is
required to offer those deemed
“Medically Frail” access to the traditional
state plan.

Medically Frail
Medically Frail
What are Alternative Benefit Plans (ABP)?
It is a set of covered services that is either:
• Based on one of three types of
commercial insurance plans or their
actuarial equivalent.
• Determined appropriate by Health and
Human Services Secretary.
In Indiana, the ABP is the Healthy Indiana
Plan (HIP).

Medically Frail
Medically Frail
Protected Classes
Indiana has established the following populations that will
have access to the traditional State Plan as opposed to the
ABP:
1. Low-Income Parent/Caretakers – those adults who are
parents or caretakers of children under 18 with income
under the Need Standard (approx. 19% FPL).
2. Transitional Medical Assistance (TMA) Program – those
who were covered as Low-Income Parent/Caretakers
whose household income has increased to between
138-185% FPL.
3. Medically Frail – individuals with serious and complex
medical conditions.

Medically Frail
Medically Frail
Protected Classes
3 in 10 nonelderly adults with Medicaid coverage
report having a disability. Of this number over half do
not qualify for SSI and SSI related Medicaid coverage.
Those disabled adults can still be eligible for Medicaid
through an Alternative Benefit Plan (ABP).
This Photo by Unknown Author is
licensed under CC BY-SA

Medically Frail
Medically Frail
Protected Classes
With the approval of the ABP, CMS has
required that states identify applicants who
are “Medically Frail” and give them access
to the traditional state benefit package.
 States must provide access to the
traditional state benefit package for
those who have been determined to be
Medically Frail.
 States may define the specific criteria
and establish the process by which
medical frailty is determined.
This Photo by Unknown Author is licensed under CC BY-SA-NC

Medically Frail
Medically Frail
Protected Classes
CMS requires that medically frail adults
include individuals with:
 Disabling mental disorders, including
Serious Mental Illness
 Chronic substance use disorder
 Serious and complex medical conditions
 Physical, intellectual or developmental
disabilities that significantly impair the
ability to perform one or more activity
of daily living
 A disability determination by the Social
Security Administration

Medically Frail
Medically Frail
Protected Classes
Indiana has designed a model that puts
Managed Care Entities (MCEs) at the center of
the determination of the Medically Frail status.
 Each MCE reviews specific diagnoses as well
as functional need criteria to make a finding
of “Medically Frail”
 Medically Frail status is reviewed annually
 There are 3 main paths to a determination of
Medically Frail
1. Application
2. Claims
3. Member or Provider Report

Medically Frail
Medically Frail - Protected Classes

Medically Frail
Medically Frail
Protected Classes
Submission of Medical records or requests for assessment of Medically Frail Status
is done by the MCE.

Medically Frail
Let’s Practice!
Meet Sean. You helped Sean with his HIP
application. He has returned and he tells
you his case manager says he needs “MRO
services”. He is not sure what that is or how
to those services. How can we help Sean?
This Photo by Unknown
Author is licensed under
CC BY-NC

Medically Frail
HIP
Approval
HIP has been approved
Submit
Records
Contact Sean’s MCE to learn
which medical records they
will need to establish
Medically Frail status
HIP
State
Plan
When MCE makes a
determination of Medically
Frail Status, MCE notifies
FSSA to change category to
HIP State Plan
MRO
Services
Clinical staff establish Level
of Need to get MRO services

Medically Frail
Medically Frail
Protected Classes
In 2018 with 24% of all HIP enrollees
designated as Medically Frail, Indiana has
the highest number of insured with this
status in the United States.

Medically Frail
14
HIP State Plans
Once identified as meeting the criteria for
a protected class, IHCP will place qualifying
HIP members in HIP State Plan. Members
can be enrolled in either HIP State Plan
Plus or HIP State Plan Basic. These HIP
members are offered access to all the
benefits under the State Plan. Cost sharing
measures are still applicable, but eligibility
cannot be terminated if the member does
not comply with Power Account
contributions.

Medically Frail
HIP State Plans
HIP State Plan Plus
HIP State Plan Plus members will
have access to all the benefits
available under the State plan.
They are still required to make
monthly Power Account
contributions and the only
copayment they have will $8 for
nonemergency ER visits.

Medically Frail
HIP State Plans
HIP State Plan Basic
This plan offers access to all
benefits under the State Plan.
Members will have the same
cost sharing requirements and
copays for services as HIP
Basic members.

Medically Frail
HIP State Plans
HIP State Plan Plus Copay
This limited enrollment plan offers the coverage of HIP State Plan Plus benefits
but requires copayments for services that match those in HIP State Plan Basic.
Enrollment in this plan is limited to HIP members with income over 100% FPL
who are also deemed Medically Frail but have not made the required Power
Account contributions. These members will not lose coverage as HIP Plus
members would, but rather will have copayments imposed.

Medically Frail
HIP State Plans
Benefits of being enrolled in the HIP State Plans:
 Access to Non-Emergency Transportation
 Access to MRO services for those meeting Level of Need (LON)
 Exemption from work program requirements
 Exemption from loss coverage if Power Account payment is not made
 HIP State Plan Basic members have access to all services under the State
Plan including vision and dental

Part 3 2022 Medically Frail

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Editor's Notes