It may sound like semantics for policy wonks, but the definition of a term will deeply impact Minnesota’s race to conform with federal Medicaid mandates.

The phrase in question is “medical frailty.” As part of changes brought on by the One Big Beautiful Bill, the Centers for Medicare and Medicaid Services was tasked with defining it before a June 1 deadline.

This determination impacts who will be exempt from new Medicaid work requirements. Minnesota and other state leaders, needing the information to start implementing the policy, were closely watching the agency’s decision.

This month they learned the definition will be far stricter than expected. Here’s what changed and why it matters for Minnesotans.

How did the definition differ from expectations?  

Most states, including Minnesota, expanded or partially expanded Medicaid access under the Affordable Care Act. Last year’s bill caused sweeping changes to the health insurance program, including imposing eligibility conditions on people who accessed care through the expansion.

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Starting next year, they’ll need to work or engage in activities like community service 80 hours per month, or attend school at a half-time clip, to qualify for Medicaid coverage. There are supposed to be exemptions, however, including for those considered medically frail. 

Examples of medical frailty range from cancer to heart disease to HIV to a mental health disorder. States expected these populations to be exempt as a matter of course, according to a KFF analysis.

But simply being medically frail won’t be enough to maintain eligibility under the new definition, said Amaya Diana, a policy analyst with KFF’s Program on Medicaid and the Uninsured.

“It’s now not just ‘Do you have cancer?’” she said of the change. “It’s “Do you have cancer, and does your condition impair your ability to work?’”

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Adopting this two-pronged approach is likely to cause administrative headaches. A KFF survey from earlier this year found states were all over the board on which definitions they used for medical frailty.

Whether they aligned with the federal government’s ultimate determination was a crapshoot. Most state definitions weren’t adopted with work requirements in mind. 

“That’s the difficult thing that states have to grapple with now is how do they pivot and set up systems in a way to identify acuity and ability to work,” Diana said. “The rule isn’t actually super clear on what states should do to make that decision.”

The June ruling was a marked departure from what Minnesota anticipated, according to a statement from the Department of Human Services.

“The Interim Final Rule released earlier this month delineates a definition of medical frailty that is a fundamental change to previous preliminary guidance,” the agency stated. “At this time, it is unclear how this new restricted definition would work in practice.”

How many Minnesotans will be impacted by this?

About 212,000 Minnesotans are in the expansion group, representing 18% of the state’s overall Medicaid population. Nationwide, about 19.8 million are expansion group enrollees. 

Within that sub-group, anyone meeting the medical frailty condition would be subject to the new rule application. The Minnesota Budget Project advocacy group condemned the change, arguing that it will reduce access to care for up to 128,000 Minnesotans. 

“The guidance is restrictive and ignores the reality of serious and complex medical conditions by reducing the number of people who can qualify for an exemption to work requirements because they are medically frail,” the organization stated in a release. “Narrowing this exemption and subjecting these folks to work reporting requirements could lead to adverse health effects caused by disruptions to their health care.”

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Greater Minnesota, where access to care is already lower, could be hit hardest. The 21 counties with the highest Medicaid participation rates are outside the Twin Cities metro, according to a Georgetown University report. 

Mahnomen, Beltrami and Nobles counties have more than a quarter of residents on Medicaid. The lowest Medicaid participation counties come in at around 15%. 

What makes these new Medicaid work requirements difficult to implement?

In practice, people who need Medicaid to stay alive will need to do a whole lot more paper pushing to maintain coverage, said Dana Bacon, senior director for state government affairs at Blood Cancer United. The organization was formerly known as the Leukemia & Lymphoma Society.

Prior to this month’s announcement, medical frailty was never viewed through the context of whether someone could work, Bacon said.

“We’ve never wanted Medicaid connected directly to work because at the end of the day, for patients, it’s health care, not work rehabilitation,” he said. “How is a doctor who’s there to practice medicine supposed to become some kind of work counselor?”

To emphasize how complicated the new rule would be, he used the example of a multiple myeloma patient. Medications keeping them in remission can reduce bone density.

How much reduction makes them unable to work? Who makes that call? How well can state coding systems take into account changes to their condition over time? All these questions came to Bacon’s mind. 

For the state’s part, DHS is seeking clarity on how to move forward. Once more details arrive, the state will put forth a proposed state plan on implementation for public comments before final submission to the federal government. 

Based on what the agency knows so far, it has great concerns that the change will contribute to “significant coverage losses among Minnesotans.” 

“As previous attempts to implement Medicaid work requirements have demonstrated, tying medical frailty to the ability to work will burden people with serious medical needs, the health care system, and state and county staff,” the agency stated.

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