Medical Frailty: Clinical Coverage Policy and Comment Period

This page provides information for NC Medicaid providers. If this does not apply to you, visit The Work and Community Engagement Requirement instead.

Starting Jan. 1, 2027, most Medicaid beneficiaries ages 19 through 64 without a disability will need to show they have a monthly income of at least $580 or meet a new work and community engagement requirement to get or keep coverage.

Beneficiaries who are “medically frail” do not have to meet the requirement.

Medically frail generally means someone has a serious health condition that significantly limits their ability to work. The draft Clinical Coverage Policy explains how Medicaid will decide who is medically frail. It is available for review and public comments. Until the final policy is approved, it is only a draft.

NC Medicaid expects to approve and post the final Clinical Coverage Policy in late November or early December 2026. It will be linked from this page.

How NC Medicaid Will Identify Medical Frailty

NC Medicaid will use two tiers of diagnosis and service codes to meet the Centers for Medicare & Medicaid Services (CMS) requirements:

Tier 1 diagnosis and service codes

Tier 1 includes diagnoses, disease categories and services that indicate a person has a condition that would significantly limit their ability to meet the work and community engagement requirement.

• Starting January 1, 2027, NC Medicaid will look for Tier 1 codes in claims and electronic health records.
• No additional provider documentation is needed if NC Medicaid can confirm a qualifying diagnosis or service through claims or electronic health records.
• Beneficiaries identified in Tier 1 by NC Medicaid do not need to submit anything else and do not have to meet the work and community engagement requirement. Their status will be reflected on the eligibility notice they get from their local Department of Social Services (DSS).
• Also, beneficiaries who are eligible for a Behavioral Health Intellectual/Developmental Disabilities Tailored Plan are automatically included in Tier 1.

Tier 2 diagnosis and service codes

A Tier 2 code alone is not enough to identify medical frailty. NC Medicaid needs more information to determine if the condition significantly limits the person's ability to meet the work and community engagement requirement. 

• If the beneficiary has a Tier 2 code, a provider should complete and sign a DSS-8209 Medical Report. The report must be signed by the beneficiary and submitted to the beneficiary's local Department of Social Services (DSS).
• If DSS cannot verify the medically frail status, a caseworker will contact the beneficiary.
• NC Medicaid plans to automate the process of finding Tier 2 cases, including combining diagnoses with qualifying services, medications or durable medical equipment. This automation will begin later in 2027.

When a Medical Report Is Needed

A provider completes a DSS-8209 Medical Report when:

• the beneficiary has a Tier 2 condition, or
• NC Medicaid cannot confirm a Tier 1 condition from claims or health records.

The provider and beneficiary must sign the DSS-8209 Medical Report before submitting it to the beneficiary's local DSS.

Resources

• Proposed Clinical Coverage Policy: H.R.1 Medical Frailty Exclusions
• Proposed: Medically Frail Diagnosis and Service Code List (Excel)
• Proposed: Medical Report — Work Requirement Exclusions and Exemptions (DSS-8209)
• All Proposed Medicaid Policies

Public Comments Open Through Nov. 5, 2026

The proposed policy, provider attestation form and medically frail code list for H.R. 1 is open for public comments through Nov. 5, 2026. You can submit comments by email to medicaid.public.comment@dhhs.nc.gov