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Addiction treatment under the ACA and the definition of "medically frail"
Addiction treatment under the ACA and the definition of "medically frail"
Posted by Anna Strong on December 2nd 2013

With Arkansas's decision to offer coverage to low-income families through its Private Option style of coverage, most uninsured adults will choose a private health insurance plan through Arkansas's Marketplace. However, DHS estimates that about 10 percent of the state's uninsured who are also earning less than 138 percent of the federal poverty level ($15,856 for an individual or $32,499 for a family of four) will be deemed "medically frail" and enroll in health coverage administered by Medicaid rather than a private insurance plan through the Private Option. Those with chronic substance use disorders (SUDs) should be in the "medically frail" coverage, but it remains to be seen which plan they will choose. 

A little background on this: 

  • Section 440.315 of recent Federal regulations published in July state that certain groups of lower-income individuals are exempt from enrolling in a state's "alternative benefit plan" (a plan such as Arkansas's Private Option plans.) Medically frail individuals are in this exempt group.
  • Essentially, this means medically frail individuals can opt into a plan administered by DHS that would likely meet their health needs better than a private-style insurance plan.
  • Though each state gets to define medical frailty, there are minimum federal requirements, including individuals with disabling mental disorders or chronic substance use disorders.

Arkansas has in place a screening tool to determine whether individuals are medically frail. Though DHS officials have said that the tool will continue to be tweaked going forward to ensure its effectiveness, the screening is in place now for the lower-income adults enrolling in coverage. The Arkansas Democrat-Gazette reported last week that 5,185 of 63,776 (8 percent) lower-income enrollees had been determined medically frail using this questionnaire. 

We have a few concerns regarding the questionnaire:  

  • The questionnaire does not mention SUDs, though it does mention mental health needs. The screening will recognize when an individual has challenges with "activities of daily living" including medication management, personal hygiene, or financial problems. However, we are concerned that the questionnaire may not capture all of those with SUDs.
  • A test by the UAMS Center for Health Literacy showed that the questionnaire for medical frailty is written at a 10th grade reading level. This is much higher than the "6th grade or below" level that is often suggested for public documents to ensure that most Arkansans can understand it.

We have mentioned both of these concerns to DHS and hope to work with them going forward to ensure those with substance use disorders are enrolling in the best type of coverage for their health care needs.

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Arkansas Advocates for Children & Families
Union Station - 1400 West Markham Suite 306 - Little Rock, AR 72201
Phone: (501) 371-9678 - Fax: (501) 371-9681 - Email: