Indiana says nearly 140,000 may be exempt from Medicaid work rules as 'medically frail'

On Tuesday, Indiana officials explained how they will apply a new federal definition of medical frailty. The definition decides which Medicaid enrollees are too sick to be held to the work requirements that begin Jan. 1 ¹. A Sept. 30 test run by the state estimated that nearly 140,000 people would qualify ¹.

The exemption covers the Healthy Indiana Plan, known as HIP. HIP is the state's version of the Medicaid expansion created by the Affordable Care Act (ACA), and it covers low-income adults. As of Sept. 30 it served about 475,000 Hoosiers, about 355,000 of them working-age adults in the expansion group ¹².

What the work rules require

The rules apply to HIP members ages 19 to 64 who are not pregnant and are not enrolled in or eligible for Medicare ⁵. Starting Jan. 1, 2027, the state will enforce them for new applicants and for renewals ⁵. Members must log at least 80 hours a month of work, volunteering, job training or school. They can also qualify by earning at least $580 a month ²⁵.

The rules also look backward. Enrollees have to show three months of qualifying activity before they apply or renew ². That means people who apply in January must have met the rules for October through December ⁵.

From Channel GOPThe bill cut Medicaid for billionaire tax breaksKamala Harris · 135 plays · captioned, with the source named

Some groups are exempt. They include parents or caregivers of a child 13 or younger, caregivers of a person with a disability, veterans rated 100% disabled, people in substance use treatment, and people found medically frail ⁵. The state's family services agency estimated on Oct. 5 that more than 58,000 current HIP members are not yet meeting the requirements ⁵.

Health insurance is not a right; it's a responsibility, and we want people to remain on the Healthy Indiana Plan

How the state will decide who is frail

The new federal definition limits medical frailty to five categories, including disabilities, disabling mental disorders, substance use disorders, and serious or complex medical conditions ¹. Having a condition is not enough. It counts only if it significantly limits a person's ability to meet the work rules ¹.

Indiana will run a tool from the consulting firm Milliman, called MARA, over its medical claims records ¹. Tier 1 looks for people with a diagnosis on the state's list. Tier 2 looks at conditions together with the treatment or services a person gets. Tier 3 lets a member, a doctor, a health plan or the state refer someone for a review by state clinical staff ¹.

The Tier 1 list has 4,288 diagnosis codes, the billing codes doctors use to record an illness ⁶. The largest group, 1,225 codes, covers cancers and other tumors. Another 939 cover muscle, bone and joint conditions ⁶. Family and Social Services Administration Secretary Mitch Roob said the definition no longer includes people with diabetes ⁴.

Anyone found frail is excused for six months at a time ¹. Officials plan to run the tool again next month and mail decisions by late November or early December ¹². The Tier 3 clinical review team has three full-time staff members ¹.

I do anticipate that we will need to build the team over time.

Mental health is a weak spot. The state expects nearly a quarter of the people it projects as frail to qualify through disabling mental disorders alone ¹. But a behavioral health diagnosis by itself does not qualify under Tier 1 ⁶. Those members will have to be picked up under Tier 2 or wait for a manual review ¹.

Coverage was already falling

The new rules arrive after a steep drop in enrollment. More than 500,000 Indiana residents have lost Medicaid coverage since the start of 2025, according to the state's dashboard, mostly after the state stepped up eligibility checks ³. A Georgetown University report found children's Medicaid coverage in Indiana fell nearly 20%, the biggest drop of any state ³.

Erika Martinez of Richmond lost her coverage when the state sent notices to her old address. She got it back only after a lot of time and effort ³. Advocates expect the number of people losing coverage could double once the work rules begin ³. The state is hiring 400 more workers ³.

When that hits, that puts us at pre-Affordable Care Act levels of uninsurance in the state

Advocates cite data showing about 70% of adults on Indiana Medicaid already work. Their worry is that the paperwork, not a lack of work, will cost people their coverage ⁷.

Why it matters for older adults

That matters because the rules hit hardest just before Medicare age. In a June 2025 analysis, the health research group KFF found that among Medicaid adults ages 50 to 64, only 48% worked 80 or more hours in the month studied, the lowest share of any age group ⁹. KFF also found that 29% of that group were not meeting the requirements and did not appear to qualify for an exemption ⁹.

The requirements come from the 2025 federal budget law that Republicans call the One Big Beautiful Bill Act. Rep. Frank Mrvan of northwest Indiana voted against it on July 3, 2025, in part because of its Medicaid cuts ¹⁰. Nationally, one projection puts coverage losses from the work requirements at up to 10.1 million people ¹¹.

I personally believe it's cruel

The pattern is clear. Republican Reps. Juan Ciscomani of Arizona, Mariannette Miller-Meeks of Iowa and Mike Lawler of New York all voted for the law and are in competitive races on Nov. 3 ¹¹. For Hoosiers, the first frailty decision letters are due in the mail weeks after Election Day ¹.

The Record

1. Jul 3, 2025Rep. Frank Mrvan votes against the One Big Beautiful Bill Act, in part over its Medicaid cuts ¹⁰.
2. Sep 30, 2026A state test run estimates nearly 140,000 HIP members would qualify as medically frail ¹.
3. Oct 5, 2026Indiana's family services agency estimates more than 58,000 HIP members are not yet meeting the work requirements ⁵.
4. Oct 27, 2026Indiana officials explain how they will apply the new federal medical frailty definition ¹.
5. Jan 1, 2027Indiana Medicaid begins enforcing HIP work requirements for new applicants and renewals ⁵.

Sources

1. Indiana Capital Chronicle (via Yahoo News), “Indiana unveils medical frailty exception to upcoming HIP work requirements” (2026-10-27). yahoo.com/news/politics/articles/indiana-unveils-medical-fra
2. Indiana Capital Chronicle (via InkFreeNews), “Indiana Unveils Medical Frailty Exception To Upcoming HIP Work Requirements” (2026-10-27). inkfreenews.com/2026/10/27/indiana-unveils-medical-frailty-e
3. WFYI Public Media (via Louisville Public Media), “Thousands already off Indiana's Medicaid rolls, before work requirements take effect” (2026-10-24). lpm.org/news/2026-10-24/thousands-already-off-indianas-medic
4. WFYI Public Media, “As work requirements loom for Medicaid, state officials worry about readiness” (2026-09-21). wfyi.org/statewide/2026-09-21/as-work-requirements-loom-for-
5. Indiana Family and Social Services Administration, “HIP: HIP Work Requirements” (2026-10-05). in.gov/fssa/hip/hip-work-requirements/index
6. Indiana Family and Social Services Administration, “HIP: Indiana Medicaid Medical Frailty Conditions List” (2026-10-27). in.gov/fssa/hip/hip-work-requirements/medical-frailty
7. Mirror Indy, “Indiana: 58,000 could lose Medicaid coverage for Healthy Indiana Plan” (2026-10-05). mirrorindy.org/indianapolis-medicaid-healthy-indiana-plan-hi
8. The Times of Northwest Indiana (via mrvan.house.gov), “Medicaid cuts set to impact all health system users, providers warn” (2025-08-04). mrvan.house.gov/media/in-the-news/medicaid-cuts-set-impact-a
9. KFF, “Different Data Source, But Same Results: Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work” (2025-06-25). kff.org/medicaid/issue-brief/different-data-source-but-same-
10. Office of Rep. Frank Mrvan, “Mrvan Hosts Medicaid Roundtable” (2025-07-29). mrvan.house.gov/media/press-releases/mrvan-hosts-medicaid-ro
11. The American Prospect, “New Medicaid Requirements Galvanizing Dems in Battleground States” (2026-10-28). prospect.org/2026/10/28/new-medicaid-requirements-galvanizin

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