Federal Judge Rejects Extra Medicaid Frailty Test, but Work Rules Still Move Ahead

Medicaid enrollees with serious or chronic illnesses will not need to prove that their condition substantially limits their ability to meet work rules in order to qualify as medically frail, after a federal judge in Boston found that the Centers for Medicare and Medicaid Services (CMS) went beyond the law. U.S. District Judge Richard Stearns sided with 25 states and the District of Columbia, concluding that the added standard exceeded what Congress authorized, the Associated Press reported via MPR News.

The ruling does not eliminate Medicaid work requirements. In most states, beginning Jan. 1, 2027, adults ages 19 to 64 covered through the Affordable Care Act’s Medicaid expansion must work, perform community service, or participate in a work program for at least 80 hours a month, or attend school at least half time, unless they qualify for an exemption.

For people living with cancer, HIV, diabetes, or a serious mental illness, the practical effect is important. Meeting one of the medically frail categories listed by Congress is enough on its own, without any separate finding that the condition limits the person’s ability to work.

The Portion of the Rule the Judge Blocked

The 2025 law known as the One Big Beautiful Bill Act exempts medically frail people from work requirements. It identifies five groups: people who are blind or disabled; people with a substance use disorder; people with a disabling mental disorder; people with a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; and people with serious or complex medical conditions.

An interim final rule CMS issued on June 1 added another requirement, saying people in those groups also had to show that their condition “significantly impairs” their ability to meet the work requirement. Stearns said that standard “is beyond the powers of CMS and thus contrary to law,” and warned that enforcing it “may lead to the disenrollment of otherwise eligible vulnerable individuals,” according to reporting on the order. Bloomberg Law reported that the decision bars CMS from enforcing that part of the rule.

Stearns also imposed a six-month stay on federal enforcement of medical frailty determinations in the plaintiff states, giving them time to adjust their eligibility verification systems. Some outlets said that means those states must wait at least six months after the work rules take effect before cutting off coverage for someone claiming a medical exemption. The stay does not apply to states that were not part of the lawsuit.

Physician groups praised the ruling. American Medical Association President Dr. Willie Underwood III called it “a victory for patients,” Medical Economics reported.

Remaining Limits That Still Apply

Two other federal limits survived the challenge. When states use claims and encounter data to assess medical frailty, they may review only the previous 12 months, so older diagnoses and records will not count. States may also accept only one self-attestation, or a person’s own statement of illness, per continuous enrollment period starting in 2028; during 2027, states may allow self-attestation each time frailty is reviewed. Stearns upheld both provisions, writing that “the government provided a non-frivolous rationale for adopting each provision.”

That could matter for people with stable conditions. Someone with a long-managed illness who has not seen a doctor in more than a year may need a recent appointment or medical record to document it.

States also retain some discretion. Eight states have decided not to accept self-attestation in 2027 and will require medical paperwork instead, Politico reported on the day of the ruling. MedicalDaily previously reported that at least six states planned to require medical proof, including Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio. Supporters of that approach have pointed to concerns about fraud. Those states can still demand proof of a qualifying condition, but under the ruling they cannot require proof that the condition significantly impairs a person’s ability to meet the work requirement.

Patients and Families Who May Benefit

Morgan Henderson, an economist who studies Medicaid at the Hilltop Institute at the University of Maryland, Baltimore County, told the Associated Press that the ruling will likely help some people obtain or keep coverage. He described people who would have lost coverage because they are sick but “not quite sick enough.”

Doctors had also objected to the extra test. “We’re not trained to decide whether someone is able to work,” Tucson, Arizona, physician Eva Shapiro told Medical Economics. CMS has said its rule does not make physicians responsible for deciding who must meet the requirement; that decision rests with states.

The financial stakes are significant at the state level. An internal analysis cited by Maryland Attorney General Anthony Brown’s office in June suggested that about 150,000 adult expansion members in Maryland, or at least 45% of that group, would be disenrolled at some point under the work requirements. The office said the estimate may understate the effect because of the stricter frailty test, which the court has now struck down. Nationally, the Congressional Budget Office projected in 2025 that work requirements in the House-passed version of the bill would increase the number of uninsured people by 4.8 million in 2034, according to a KFF analysis.

North Carolina, one of the states requiring documentation, welcomed the ruling. Dev Sangvai, the state’s health and human services secretary, said one of the state’s priorities is making sure people can get needed care “without facing confusing paperwork or the fear of losing coverage during treatment.” CMS declined to comment and has not said whether it will appeal. A separate lawsuit filed in September by physician groups, Medicaid enrollees, and the City of Columbus, Ohio, challenging the self-attestation limits is pending in federal court in Maryland.

Preparing for the Rollout

People enrolled in expansion Medicaid should first check whether the work rules apply to them, since many groups are exempt, including pregnant and postpartum people, parents and caretakers of children 13 and younger, and disabled veterans. State Medicaid websites and screening tools can help.

Those who believe they are medically frail should make sure their condition has been documented within the past 12 months. Scheduling a routine visit before the rules take effect and asking the clinic for a copy of the records can help avoid problems later.

Enrollees should keep their mailing address, phone number, and email current with the state Medicaid office and open every notice. Under federal rules, enrollees who receive a noncompliance notice have 30 days to show they meet the requirement or qualify for an exemption before coverage ends. Legal aid groups and community health centers can help with appeals.

Emergency care should never be delayed because of coverage concerns. Hospitals must still screen and stabilize patients in an emergency.

Key developments to watch are whether CMS appeals and whether it issues revised federal guidance before the work requirements take effect.

Questions and Answers

What did the judge decide? Judge Richard Stearns ruled that CMS exceeded its authority by requiring medically frail enrollees to prove their condition significantly impairs their ability to meet work requirements.

Are Medicaid work requirements canceled? No. The 80-hour monthly requirement for expansion adults ages 19 to 64 still begins in most states on Jan. 1, 2027.

What parts of the rule remain? The 12-month lookback for frailty data and the limit of one self-attestation per continuous enrollment period, which starts in 2028, were both upheld.

Who counts as medically frail? People who are blind or disabled; people with a substance use disorder or a disabling mental disorder; people with a disability that significantly impairs daily activities; and people with serious or complex medical conditions.

What is the six-month stay? It pauses federal enforcement of frailty determinations in the plaintiff states for six months so they can update their verification systems.

Will CMS appeal? CMS declined to comment and has not announced an appeal.

What should enrollees do now? Confirm whether work requirements apply, make sure any qualifying condition is documented within the past 12 months, and respond quickly to state notices.