A federal judge in Boston on Thursday, October 29, blocked the Trump administration from enforcing a rule that would narrow who counts as 'medically frail' — and therefore exempt from new Medicaid work requirements — siding with 25 states and the District of Columbia. U.S. District Judge Richard Stearns ruled that the Centers for Medicare & Medicaid Services (CMS) had unlawfully limited the exemption, Reuters reported.
Source: Reuters via SRN News
Stearns wrote that CMS's definition was beyond the agency's powers. Congress itself set out five categories of people who count as medically frail, and the judge found that some people in those categories might not qualify under CMS's narrower test, Fierce Healthcare reported. 'The court agrees with the States that the agency lacked authority to exclude any subset of individuals in the five subcategories delineated as medically frail by Congress,' Stearns wrote, in a passage quoted by Bloomberg Tax.
What CMS tried to add
Medicaid is the U.S. health insurance programme for low-income Americans, jointly funded by the federal and state governments. CMS issued its rule in June 2026 to implement work requirements enacted in the One Big Beautiful Bill Act, President Donald Trump's signature tax and spending measure, which he signed into law last year.
The law requires most adults aged 19 to 64 to complete at least 80 hours a month of work or community engagement, or be enrolled in an education programme at least half time, to qualify for Medicaid beginning January 1, 2027. It exempts people who are 'medically frail or otherwise have special medical needs.'
CMS's rule added a second hurdle to that exemption: a person would count as medically frail only if a 'physical, mental, or other behavioral health condition significantly impairs the individual's ability to comply with the community engagement requirement.' Stearns said that extra test unlawfully narrowed the group Congress had exempted.
'Because 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 States (and public) face potential for great hardship in the absence of an injunction,' Stearns wrote. Fierce Healthcare reported he said the court would issue the permanent injunction the states had requested.
Not a complete win for the states
The ruling did not strike down the work requirements themselves, and it was not a complete win for the states. Stearns upheld other provisions the states had challenged, including one barring states from relying on proof of a patient's medical frailty that is more than 12 months old, Reuters reported. Fierce Healthcare reported that, under the order, CMS should offer states a six-month stay of enforcement on frailty determinations, given the short timeline before the January rollout.
CMS declined to comment on the ruling, Reuters reported.
California Attorney General Rob Bonta, one of the attorneys general who led the challenge, welcomed the decision. 'People with serious illnesses or disabilities should not have to worry about losing their healthcare because of work requirements or related barriers,' Bonta said in a statement reported by Reuters. 'That's not what Congress intended.' California, Massachusetts and New Jersey led the lawsuit, which was filed in June.
How the case reached this ruling
The coalition sued in June, arguing among other things that states did not have the resources or the time to build the systems the June rule required, that enrollees had to be notified by August 31 even though the requirements start in January, and that states faced significant potential fines if they failed to comply with the final rule, Fierce Healthcare reported at the time. Massachusetts Attorney General Andrea Joy Campbell said then that Congress had made clear people with serious medical conditions should not lose coverage.
In July, Stearns refused the states' request to pause the rule while the case went forward, noting CMS said it would reimburse 90 percent of the cost of setting up the eligibility systems, but he said that decision did not reflect his view on the merits and that he aimed to rule before January 1, Fierce Healthcare reported. Thursday's ruling is that merits decision on the frailty definition.
Experts cited by Fierce Healthcare have warned that the administrative burden of proving work hours — and of proving an exemption — is likely to push millions of people off the Medicaid rolls, including people who are working or who qualify for an exemption but cannot keep up with the paperwork. For low-income families, including Punjabi diaspora households in California's Central Valley, New York, New Jersey and other states where many readers work in trucking, warehouses, farms and small businesses with variable hours, the frailty definition decides whether a seriously ill family member must document 80 hours a month or risk losing the coverage their treatment depends on.
What happens next
The work requirements themselves still take effect nationally on January 1, 2027; only the narrowed frailty definition is blocked. States must continue building eligibility systems on that timeline, now without CMS's extra 'significantly impairs' test for the frailty exemption. Medical Economics, citing Politico, noted the ruling adds uncertainty for doctors and state officials — including in Indiana and Michigan, which had recently published plans to use claims data to decide who is exempt — and that it was not immediately clear how the decision applies to states that did not join the lawsuit. Whether the administration appeals, and how CMS rewrites its guidance to states, are the next developments to watch.