Gainwell Launches AI-Powered Tool to Identify Medically Frail Medicaid Members—Offers Core Logic to States at No Charge
IRVING, Texas, March 31, 2026 (GLOBE NEWSWIRE) -- Gainwell Technologies LLC today announced a new solution to help state Medicaid agencies identify medically frail members as part of Community Engagement Verification (CEV) programs required under H.R. 1. As part of its pledge to CMS, Gainwell is making the underlying proprietary clinical logic—the rules that determine whether someone qualifies as medically frail—available to every state Medicaid agency at no cost, regardless of their technology partner.
New federal rules under H.R. 1 require states to quickly and accurately determine which Medicaid members are medically frail and therefore exempt from work requirements. States must make these determinations using claims data and other available sources, often with limited staff and complex data systems. The Gainwell solution uses clinician-developed rules combined with advanced AI to make these determinations accurately and consistently, so that people with serious health conditions don't lose benefits they depend on.
Logic built by Gainwell clinicians with more than 2,000 clinical codes is available free to states
As a leading Medicaid Management Information System (MMIS) provider, Gainwell has national expertise in claims data across the country, which is a significant advantage when it comes to identifying frailty within medical records. The Gainwell clinical team developed a comprehensive set of rules covering more than 2,000 codes across medical, behavioral health, and pharmacy claims.
The logic goes beyond simple code-matching: it cross-references related conditions, factoring in how recent, frequent, and severe clinical events are to distinguish between temporary and permanent frailty. This logic is available at no cost to all states even if they choose a different implementation partner.
“We created this logic because medically frail members deserve uninterrupted access to the care they rely on. As states navigate the new H.R. 1 requirements, we wanted to give them a simple, reliable way to identify and protect those individuals,” said Gary Call, M.D., Gainwell Chief Medical Officer. “Our priority is to ease the burden on state teams while safeguarding the people whose health depends on Medicaid.”
Logic also available as part of discounted Medical Frailty or comprehensive CEV solutions
For states that have a different implementation partner for broader Community Engagement Verification, Gainwell offers its medical frailty solution as a standalone, discounted service that works with any MMIS or eligibility system.
States can also add on capabilities to go beyond claims data—including state health information exchanges, unemployment disability records, workers’ compensation, and all‑payer claims databases, to identify individuals who cannot be assessed through claims alone. The clinical rules update automatically based on latest CMS guidance, so states don’t have to manually track regulatory changes.
An optional add-on can also help states handle paper-based verification by automatically reviewing provider forms and member questionnaires to extract relevant frailty information to reduce manual review work while improving accuracy.
For states that want a complete solution, the medical frailty solution is included in the Gainwell full Community Engagement Verification platform, available at a discounted price as part of Gainwell’s pledge to CMS. Gainwell is proud to be a trusted partner for states to implement CEV solutions by meeting them where they are in their journey.
Gainwell data and innovation experts Yasin Turkcan, SVP, Product & Innovation, John Morales, Director, Data & Analytics, and Jake Kobza, Director, Product Management explain more about the challenges and importance of medical frailty verification in this new blog post.
For more information, please visit Medicaid Eligibility Verification Solutions - HMS | Gainwell.
About Gainwell Technologies
Gainwell Technologies LLC is the trusted leader in digital and cloud-enabled solutions for health and human services programs. With over 50 years of proven expertise, we help modernize Medicaid and public health programs with innovative solutions to improve operational efficiency and enhance provider experiences, while also safeguarding program integrity with HMS verification and cost containment services. Combining cutting-edge technology with an unwavering commitment to service excellence, Gainwell delivers scalable, impactful solutions that advance public health and create transformational results. Learn more at gainwelltechnologies.com.
Media Contact
Cecile Fradkin, S&C PR for Gainwell, cfradkin@scprgroup.com
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