Kentucky HEALTH has a new exemption category called “Medically Frail.”
As a part of the Kentucky HEALTH 1115 Waiver, enrolled adults can be determined to be Medically Frail if any of the following criteria apply:
- The individual is chronically homeless
- The individual is a survivor of domestic violence
- The individual has a disabling mental disorder (including serious mental illness)
- The individual has a chronic substance use disorder (SUD)
- The individual has a serious and complex medical condition, or a physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living
If an adult enrolled in the waiver is determined to be Medically Frail, it can alter the enrollment circumstances for that individual:
- Premium payment for the Medically Frail individual is optional;
- Community engagement participation for the Medically Frail individual is optional;
- Medically Frail individuals are not subject to the same suspensions for:
- Premium payment non-compliance;
- Community engagement non-compliance;
- Voluntary Withdrawal;
- Failure to recertify;
- Failure to report case changes
Medically Frail Determination
Per the Kentucky HEALTH 1115 Waiver, an individual may be determined to be Medically Frail in two different ways:
- Claims analysis using a DMS-provided tool
- Clinical attestation by a Kentucky Medicaid Provider
WellCare will perform a periodic analysis of all claims received for WellCare members, and every member will receive a complete analysis on, at least, a monthly basis. Through this claims analysis, WellCare will ensure that any member with a medical history that satisfies that DMS-provided tool’s criteria is identified as being Medically Frail.
Members identified through the claims analysis will be reported to DMS on a daily basis, and no further action needs to be taken by providers.
In some circumstances, the medical history of the member will be insufficient to identify the member as Medically Frail. Some examples include:
- Members newly enrolled in WellCare without a sufficient claims history;
- Members who self-identify as being Medically Frail at enrollment, but who lack diagnostic evidence of chronic conditions in their available claims history;
- Members who have some evidence of applicable conditions in their claims history, but not sufficient volume or acuity to qualify as Medically Frail based on the DMS tool;
- Members who are Frail because of chronic homelessness or inability to complete activities of daily living;
When a member could be considered Medically Frail, but the identification cannot be completed solely on the basis of the DMS tool, Kentucky Medicaid providers can complete the Kentucky Medically Frail Clinician Attestation to determine whether the member qualifies for this status.
The attestation can be completed by any provider enrolled with Kentucky Medicaid who is operating within their scope of practice. Printed forms may be completed and faxed to <FAX NUMBER> Instructions for completing the paper form can be found at <location>.
The attestation may also be completed electronically through the WellCare Provider Portal. Detailed instructions for completing the online form are available at <website>.
Please be aware that clinical attestations are not evaluated in real-time, and completing a form for a given member does not guarantee that member will be considered Medically Frail. Clinical attestations must be evaluated by WellCare, and those evaluations will be provided to DMS. Only when DMS validates the attestation results and updates the eligibility status of the member will the member be considered to be Medically Frail.