Federal Judge Blocks CMS Rule Tightening Medicaid 'Medically Frail' Exemption, Upholds Two Other Limits

A federal judge in Boston ruled today, Oct. 29, that the Trump administration went too far in defining who counts as "medically frail" under the new Medicaid work requirements. He left the requirements themselves in place.

U.S. District Judge Richard Stearns gave a partial win to 25 states and the District of Columbia. They sued in June over guidance from the Centers for Medicare and Medicaid Services (CMS) implementing the 2025 "One Big Beautiful Bill."

What the rule added

The statute says the medically frail category must include people who are blind or disabled, have substance use disorders or disabling mental disorders, have certain disabilities that significantly impair daily activities, or have serious or complex medical conditions.

The CMS rule added a second hurdle. People in those categories had to show their condition also "significantly impairs" their ability to comply with the work requirement itself.

The states argued that added test would keep eligible people from care and goes beyond the text Congress wrote. Stearns blocked it.

In his 16-page ruling, he found the states had shown irreparable harm that money damages could not fix. "They face the burden of costly and intensive alterations to their eligibility verification systems," he wrote.

He also wrote that enforcing "an unlawful definition of 'medically frail' may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care." He gave states a six-month stay of enforcement for medically frail determinations, according to the Epoch Times.

What the government kept

The administration did not lose across the board. Stearns upheld two other federal limits on how states verify frailty.

States must reject proof of frailty if the diagnosis is more than a year old. States may also accept only one self-attestation per continuous period of enrollment.

He said the states had not cleared the bar on those provisions. "The government provided a non-frivolous rationale for adopting each provision and explained why it did not find the States' concerns of disenrollment compelling," Stearns wrote.

The work requirements are not struck down. The law requires expansion enrollees aged 19 to 64 to work, volunteer, train or attend school for at least 80 hours a month. Other exemptions include pregnancy and parenting children of certain ages.

Reaction

The American Medical Association welcomed the decision. President Willie Underwood III called it a victory for patients that "strikes back against unnecessary barriers to care." He said the court "rightly rejected a federal restriction that would have made it harder for people with serious or complex health conditions to qualify for an exemption."

Morgan Henderson, an economist at the Hilltop Institute at the University of Maryland, Baltimore County, said some people will likely keep coverage as a result. He pointed to "those individuals who would have lost coverage because they're sick but they're not quite sick enough."

North Carolina Health and Human Services Secretary Dev Sangvai said the ruling helps people avoid "confusing paperwork or the fear of losing coverage during treatment."

A CMS spokesperson told the Epoch Times the agency does not comment on pending litigation. HHS and CMS had not responded to the Associated Press's request for comment.

The text-versus-guidance fight

The core dispute is narrow and legal. Congress listed categories of people who must be treated as medically frail. CMS then layered an extra functional test on top of that list.

The administration's reasoning for that specific test is not in the public record of today's coverage, since CMS declined to comment. The only government rationale on the record is what Stearns described for the two provisions he upheld: the verification limits drew a non-frivolous justification, and officials weighed the states' disenrollment concerns and found them unpersuasive.

The split affects taxpayers and enrollees alike. The ruling does not touch the principle that able-bodied expansion adults must work or serve to qualify. It says an agency cannot add conditions to categories Congress already defined.

What comes next

The requirements apply to expansion enrollees, the group covered in most states through the program's expansion, starting Jan. 1, 2027. CMS faces that deadline for implementation.

States now have to build their verification systems around a definition that no longer includes the extra work-impairment test. Whether the administration appeals the decision has not been announced.