Indiana’s Family and Social Services Administration laid out Oct. 27 how it will decide which Medicaid expansion members are “medically frail” and exempt from work requirements that start Jan. 1, 2027. HIV didn’t make the automatic list.
Medicaid Chief Clinical Officer Katrina Etter presented the three-tier system at FSSA’s quarterly financial meeting, the Indiana Capital Chronicle reported. The state’s screening tool, run Sept. 30, put the number who’d qualify at nearly 140,000.
People living with HIV could still get the exemption, a state spokesperson told WFYI, but they’d have to provide proof.
Indiana’s Tier 1 Frailty List Includes Anthrax and Rabies but No HIV Codes
FSSA’s posted Tier 1 diagnosis list includes anthrax, rabies and a herpesvirus infection. HIV was absent from the published diagnosis tables when Gayety checked them Oct. 29. The state says it will update the information as it becomes available.
Two other tiers assess people who do not qualify by diagnosis alone. One considers claims evidence such as treatment, medication and services. The other is an individual review by state clinical staff, who can consider records submitted by a member, provider or managed care organization.
“So, for example, you could have a member with depression,” Etter said, according to WFYI. “They would not qualify based on diagnosis alone, but if they had evidence of treatment in a setting that would indicate a severity that could be functionally limiting, they would qualify through that tier two pathway.”
The screening runs on a tool called Milliman Advanced Risk Adjusters. “We have specifically customized it for the purpose of evaluating claims against the new federal definition,” Etter said. Exemptions will last six months at a time.
People the tool misses “can submit supplemental information for our clinical team to review,” Medicaid Chief Operating Officer Lindsey Lux said. That team has three full-time staffers for now, the Capital Chronicle reported.
Damien Center’s Alan Witchey on HIV Medication and Indiana Medicaid
Alan Witchey runs the Damien Center, an HIV nonprofit in Indianapolis. A lot of people living with HIV count on Medicaid for their meds, he told WFYI.
“The reason why that’s important is that people living with HIV are on medications,” he said. “If you stop taking your medications, your health will dramatically or can dramatically change.”
“Waiting until a person experiences significant functional impairment, opportunistic illness, or other complications before protecting access to care is inconsistent with the fundamental purpose of HIV treatment: preventing disease progression in the first place,” Witchey said.
Social workers raised that worry at a September FSSA town hall. “HIV used to fall under medically frail,” Shawn Delmolino of IU Health’s LifeCare HIV clinic said, the Capital Chronicle reported. “It seems like it’s questionable now.”
The term “medically frail” has been used for a different purpose in HIP: determining which benefits a member receives. FSSA’s presentation says the new definition instead determines exemption from work requirements. A prior medical frailty designation is not the same as approval under the new rules.
About 14,900 Hoosiers were living with diagnosed HIV, including AIDS, at the end of 2024, state health data show.
CMS Rule Says an HIV Diagnosis Alone Doesn’t Make Someone Medically Frail
The federal rule behind all this, issued by CMS on June 1, names HIV as an example of a serious condition. But it says significant impairment is “less likely to be the case if the acuity of their condition is not severe,” according to the rule text KFF quoted. Nationally, 46% of people with HIV had Medicaid in 2023, KFF found.
HIP members ages 19 to 64 who are not exempt can meet the requirement through 80 hours a month of work, volunteering, training or a combination of eligible activities, or by earning at least $580 a month. Attending school or an apprenticeship at least half time also qualifies, under FSSA’s rules.
The requirements begin with applications and eligibility renewals initiated on or after Jan. 1, 2027. Applicants in January must meet the requirements for October, November and December, the state’s FAQ says.
FSSA’s Oct. 27 presentation, using Sept. 30 data, identified 54,530 expansion members who still needed to show compliance. That is not a count of people who have already lost coverage.
“We didn’t create the Healthy Indiana Plan to kick people off,” FSSA Secretary Mitch Roob said, WFYI reported.
Etter said decision letters go out by late November or early December.
