Judge strikes down Trump admin's definition of 'medically frail' in Medicaid work rules

A federal judge in Boston sided on Thursday with a coalition of 25 Democratic-led states and the District of Columbia in a lawsuit challenging the Trump administration's requirement that states force chronically ill people on Medicaid to prove they are unable to work .

During oral arguments last week, the states said that unless the court blocked that piece of the rule before January and allowed them to exempt people with certain diagnosed illnesses, they would be "forced… to bear the costs and burdens of operationalizing this unlawful limitation."

Judge Richard Stearns, an appointee of President Bill Clinton, said the guidance the Centers for Medicare and Medicaid Services released in June went beyond what Congress passed in 2025 in the One Big Beautiful Bill Act , and is "thus contrary to law."

"There is an inherent public interest in ensuring that the government follows the law," he said, adding that "enforcement of an unlawful definition of 'medically frail' may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care."

The One Big Beautiful Bill Act mandated that people who receive Medicaid through the expansion of the program created in the Affordable Care Act — typically low-income people without young children — must work, volunteer or go to school for 80 hours a month to keep their benefits. But it exempted people too medically frail to work.

The court also ordered states to hold off for at least six months after the work rules take effect before they cancel the health insurance of anyone claiming a medical exemption to give them time to update their verification systems to comply with the ruling.

The ruling blocks only the "medical frailty" portion of the law and leaves the rest of the Medicaid work requirements, which will be enforced nationally beginning in January, in place.

CMS declined to comment on the decision and whether they plan to appeal it.

The ruling follows months of turmoil around the country as states raced to implement the Medicaid work requirements before the January deadline. Doctors, hospitals, community health centers and patient advocacy groups have been raising alarms about the burden placed on them by the Trump administration's medical frailty rule — arguing they will be forced to spend time and resources they don't have on the what they view as the often impossible task of evaluating chronically ill patients' ability to work.

"We're trained to do preventive care and help people navigate their illnesses. We're not trained to decide whether someone is able to work," Eva Shapiro, a physician in Tucson, Arizona, told reporters on a press call about the rules last week. "Patients with chronic conditions may have good weeks and bad weeks, and even those who are working may have difficulty navigating additional paperwork and reporting requirements."

Stearns reject challenges from the states to other aspects of the law. The judge, for instance, sided with the government on a requirement that states reject proof of patients' medical frailty — like a hospital admission or diagnosis — that is more than 12 months old.

States argued the provision will lead to greater disenrollments because sometimes a frail individual will go longer than 12 months between major health services.

The judge ruled that CMS provided a rationale for that "lookback" provision and therefore it was not arbitrary as the states contended.

"That the states (or even the court) may disagree with the wisdom of the agency's policies and conclusions, or may have made different choices, is irrelevant," he wrote.

Stearns also sided with the Trump administration on its policy letting states decide whether or not to accept a patient's pledge that they are too sick to work in lieu of proof for the first year the work requirement is in effect.

Starting in 2028, Medicaid expansion enrollees nationwide can self-attest once but then during their next renewal they must prove that their condition prevents them from working.

Eight states have rejected the one year grace period and will require that paperwork in 2027, arguing that allowing patients to "self-attest" could lead to fraudulent enrollments.

The states' case argued that the Trump administration should have required all states to accept self-attestation of medical frailty.

Another lawsuit challenging the policy, filed by medical groups and the city of Columbus, Ohio, remains pending in a Maryland federal court.