Up to 10.1 million fewer people could be on Medicaid expansion coverage in 2028 under OBBBA work requirements and six-month renewals, in the Urban Institute’s low-mitigation projection. A meaningful share of them may qualify for a medical-frailty or caregiving-role exemption, but only if the documentation exists when the state checks. We are building the workflow that produces it: an AI draft, then a physician who signs it or declines it with the reason in writing. Planned, not open.
Two inputs. Every number below is a model with its source named; replace the defaults with your own and the arithmetic updates. When you want the real cohort, the ROI report below uses your de-identified panel.
The model assumes every at-risk member who is not documented loses coverage, which overstates loss (some will comply or self-attest) and ignores members who lose coverage for non-hour reasons, which understates it. It is for sizing a conversation, not a budget line. Your ROI report replaces these assumptions with your panel.
OBBBA adds work requirements for able-bodied adult Medicaid enrollees. States must verify compliance. Enrollees who fail verification lose coverage. For health systems, disenrollment is revenue lost and uncompensated care incurred. The exemption process is the relief valve — if you file.
CMS's interim final rule took effect July 31, 2026. States are building auditable condition lists and wiring the prior twelve months of claims and encounter data in as a verification source. What is in your structured record is now an input to the state's determination. → build the dated record
The window to identify at-risk patients, flag exemption candidates, and pre-file attestations before first redetermination. → ROI report
States begin applying work-verification. First redetermination cycles start rolling. Disenrollment begins. → size it
Without intervention: 10M disenrolled nationally (CBO). One health system, Guthrie, has put its own figure on the record — see below.
Guthrie — a nonprofit system across rural Pennsylvania and New York — told Spotlight PA how much net revenue it stands to lose from the federal Medicaid changes. About 70% of its patients carry government-funded insurance; 16% are on Medicaid. So it did something most systems have not done yet: it started treating enrollment retention as an operating function instead of a policy problem.
Not a national projection. One mid-size rural nonprofit put its own net revenue at risk on the record, through its chief operating officer. Run the same arithmetic against your Medicaid mix before your budget cycle closes.
Read the Spotlight PA report →Out of 2.8 million Pennsylvanians on Medicaid — 22% of the state. State officials also anticipate a federal funding loss over the ten years beginning 2028. Every state has a version of this number.
PA DHS data reports →Guthrie expanded its volunteer program so patients can meet the monthly requirement on campus — greeting visitors, the gift shop, events, deliveries — and is calling Medicaid recipients directly to walk them through the new rules. Pennsylvania’s human services secretary called the system a trusted resource for helping people meet the requirement and stay covered.
See their program →This is the right instinct and the right economics — a covered patient is a reimbursed patient, so retention belongs in revenue cycle. But it only closes one of the two doors. Community engagement works for the patient whose barrier is a scheduling gap. It does nothing for the patient whose barrier is clinical: the COPD exacerbation, the chemotherapy calendar, the psychiatric admission, the dementia caregiving load at home. Asking that patient to volunteer 80 hours is asking them to do the thing their condition prevents.
Peer-reviewed data published in JAMA Health Forum in August 2026 sizes that group: across all 40 expansion states, 19.8% of eligible adults are at risk of missing the hours — and the study's lead author flags the specific population caught in between, those with “substantial health concerns that may not rise to the level of a documentable disability.” Too sick to hold predictable hours, not disabled enough for an automatic pass. For a health system, that is a named, findable cohort sitting inside your own EHR.
Those patients need the other door: a physician-signed frailty attestation filed against the federal “significantly impairs” standard, where the state accepts it (each state decides which clinicians’ documentation counts, and many look to the treating provider). Same retention goal, same revenue logic, different instrument — and it is the one your organization already has the clinical evidence to produce. A complete Medicaid retention program runs both. Guthrie has built one. We are planning the other.
Size the exemption-eligible cohort in your panel →Three steps, all planned. Find who may qualify, prepare an AI draft from the record, and have a physician review it and sign or decline with the gap named. Review window agreed at contract. A log of each step.
You would send a de-identified patient list by a method agreed at contract; there is no upload portal. The planned match compares diagnosis codes, medications and caregiving flags to the federal exemption criteria and returns a candidate list with the criterion to check for each. The estimator below is what exists today.
A draft is prepared in plain language from what the record shows, citing the supporting diagnoses and encounters and following your state's fields. It is a draft only. Nothing leaves the physician's queue unreviewed.
Our medical director would read every draft and either sign it or send it back with the specific gap. The review window is agreed at contract, not assumed. Your compliance team gets a log: draft, edits, signature, date.
The AI prepares a draft and never signs. A physician reads it and either signs it or declines it with the reason in writing. This is the plan; review is not open yet.
Send an anonymized panel summary (counts by ICD-10 group, age band, and caregiving flag — no PHI). Within two business days we return a confidential report with:
No commitment. No PHI required (de-identified counts only). Reviewed by our medical director.
We follow up within one business day to confirm file format and security requirements.
No federal rule requires one. The federal work-requirement rule lists the exemptions, and each state decides how it checks them: its own records first, then the documentation it accepts, which in many states can come from the treating provider. A physician-signed attestation is one way to document it, and it is planned here, not open. The open question for a health system is whether the documentation exists when a state checks, from 2028, at redetermination.
Our physician of record is our medical director, a physician licensed in all 50 states and DC. Each case is checked against the member’s state before review, and nothing is charged where review isn’t open. Having one physician decide every case means a single, consistent standard of review, and one physician an auditor can interview.
Plainly: we do not accept PHI today. The ROI report runs on de-identified panel counts. Before any PHI is exchanged, a BAA is signed and the intake path is one the reviewing physician controls. We do not currently operate a HIPAA-audited cloud environment, a FHIR ingestion service, or a SOC 2 program; those are scoped and will be described as built, not before. If your security team needs a data-flow diagram of what exists now, we will draw the honest one.
Not yet. Today the input is a CSV/XLSX of a de-identified panel. EHR integration (FHIR R4 against Epic, Cerner, Athena, Meditech) is scoped and is not built. We will not describe it as available until it is running against a live system.
The draft goes back with the gap named in writing. Your team either provides more documentation or removes that patient from the cohort. Nothing is submitted without a physician signature.
No turnaround is promised. A first batch of attestations would be scoped with you after the BAA, and the binding constraint is the physician review window, which we would agree in writing rather than promise. We would rather tell you a true date than a fast one.
Same physician of record, different buyer. The consumer product at medfrail.com gives individual families a dated record that stays on their device, and a physician-review list; nothing is charged there today. This enterprise product is for health systems and Medicaid plans and is not priced yet. Any attestation we issue will be physician-signed.
Your Medicaid panel's first redetermination cycle is closer than your budget process thinks. The systems that identify, file, and protect ahead of the curve will keep their patients. The systems that don't will write uncompensated care into next year's variance report.
Get your Exemption ROI Report →