A federal judge in Boston has struck down a Trump administration rule that narrowed the medically frail exemption to Medicaid’s new work requirements, a change that would have forced people with serious conditions to prove their illness keeps them from working. U.S. District Judge Richard Stearns ruled on October 29 that the Centers for Medicare and Medicaid Services, the federal agency that runs Medicaid, went beyond what Congress allowed.
The work requirements come from the 2025 budget law known as the One Big Beautiful Bill Act. Starting January 1, 2027, most adults ages 19 to 64 who get coverage through Medicaid expansion, the option that lets states cover more low income adults, must work, volunteer or take part in job training for 80 hours a month, or attend school at least half time, to keep their coverage. States can ask for a delay of up to two years. The law exempts people who are medically frail, which it defines to include people who are blind or disabled, people with a substance use disorder or a disabling mental disorder, people with disabilities that significantly affect daily living, and people with serious or complex medical conditions.
In June, the agency issued an interim final rule, a regulation that takes effect while the public is still commenting on it. According to the Healthcare Financial Management Association, the rule added a test the law did not contain: a qualifying condition counted toward the medically frail exemption only if it significantly impaired the person’s ability to meet the work requirement, and providers had to document both the illness and the impairment.
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A coalition of 25 states and the District of Columbia, led by California, Massachusetts and New Jersey, sued in a case called Commonwealth of Massachusetts v. Oz. Stearns found that the law did not authorize the extra test. He vacated that part of the rule, meaning he wiped it off the books for the entire country, and permanently barred the agency from enforcing it. For the states that sued, he also paused federal enforcement on medical frailty decisions for six months after the requirements begin, which CBS Austin reports means those states must wait at least six months before canceling coverage for someone claiming a medical exemption.
The judge did not side with the states on everything. He upheld the agency’s power to reject medical records older than 12 months as proof of frailty, and he allowed a limit, starting in 2028, that lets a person vouch for their own condition only once per continuous stretch of enrollment.
North Carolina Attorney General Jeff Jackson, whose state joined the suit, said “Congress specifically protected these patients, and CMS broke the law by trying to take that protection away.” The Daily Tar Heel reports that the restriction would have affected an estimated 64,000 North Carolinians. The federal Department of Health and Human Services and the agency did not immediately comment and did not say whether they will appeal. A separate case challenging the same limits, Taylor v. Kennedy, is pending in federal court in Maryland.
The ruling does not stop the work requirements themselves. Unless a state has been granted a delay, they take effect January 1, and anyone who believes they qualify for the medically frail exemption can confirm how to claim it with their state Medicaid agency.
