Judge bars CMS rule requiring Medicaid patients to prove frailty impacts work

A federal judge in Boston ruled Thursday that chronically ill Medicaid beneficiaries are not required to prove their conditions prevent them from working, blocking a key part of the Trump administration's latest guidance. U.S. District Judge Richard Stearns issued the decision against the Centers for Medicare and Medicaid Services, siding with a coalition of 25 states and the District of Columbia that filed suit in June.

The dispute centers on the definition of medical frailty under the 2025 One Big Beautiful Bill. The law lists specific groups, including people with disabilities, substance use disorders, and complex medical conditions, as eligible for exemptions from new work requirements. The CMS rule added a layer, requiring these individuals to show that their conditions significantly impair their ability to comply with those work mandates. Stearns found that this extra step goes beyond the text of the law.

The ruling preserves coverage for many recipients who are sick but not severely disabled enough to meet the agency's stricter threshold. Morgan Henderson, an economist at The Hilltop Institute at the University of Maryland, Baltimore County, said the decision likely keeps coverage for those who would have lost it. He noted that individuals who are ill but not quite sick enough to meet the previous standard may now have their coverage preserved.

The decision offers relief to state agencies that must manage eligibility. North Carolina Health and Human Services Secretary Dev Sangvai said in a statement that the ruling helps patients avoid stressful paperwork and fear of losing care during treatment. He emphasized that the state can now focus on delivering reliable healthcare to vulnerable residents without the burden of verifying complex medical impacts on daily work capacity.

Stearns did not strike down the work requirements themselves. The new rules, effective Jan. 1, mandate that expansion enrollees aged 19 to 64 work or perform community service for at least 80 hours a month or attend school at least half-time. Exceptions exist for those deemed medically frail or in addiction treatment. The judge determined that the government met its burden in arguing that states face irreparable harm through costly alterations to their eligibility verification systems if the stricter rule stands.

The judge upheld two other federal restrictions on how states verify medical status. He maintained the requirement that states reject proof of frailty if the diagnosis is more than one year old. He also upheld a policy allowing states to accept only one self-attestation per continuous period of enrollment. Stearns explained that the government provided a non-frivolous rationale for these provisions and did not find the states' concerns about disenrollment compelling in those specific areas.

The CMS declined to comment on the ruling. The new restrictions apply to Medicaid expansion populations in most states, which expanded access to government safety net healthcare for lower-income residents in recent years. The court order means state agencies can proceed with enrollment processes without enforcing the specific impairment-to-work-requirement link for the duration of the litigation.

The lawsuit was filed by a group of state officials arguing that the administrative rule oversteps statutory limits. The decision leaves the broader framework of the 2025 law intact while removing one specific hurdle for medically vulnerable beneficiaries. State administrators will now adjust their verification systems to align with the court's interpretation of the medical frailty definition.