A federal judge in Boston blocked part of Trump administration guidance that would require chronically ill Medicaid recipients to prove their conditions significantly impair their ability to comply with work requirements, in a partial victory for 25 states and the District of Columbia.
U.S. District Judge Richard Stearns ruled Thursday that states need not apply the stricter test for "medically frail" exemptions under new work requirements for Medicaid expansion enrollees. The plaintiffs, a coalition of states and DC, sued in June over Centers for Medicare and Medicaid Services guidance tied to the 2025 law known as the "One Big Beautiful Bill."
The law defines medically frail to include people who are blind or disabled, have substance use disorders or disabling mental disorders, have certain disabilities that significantly impair daily activities, or have serious or complex medical conditions. The CMS rule went further, requiring those people to show their conditions also "significantly impair" their ability to comply with the work requirements.
In his 16-page ruling, Stearns said the states met their burden of showing irreparable harm for which monetary damages would provide inadequate compensation, citing the burden of costly and intensive alterations to their eligibility verification systems. The ruling does not strike down the work requirements themselves.
Stearns upheld two other federal restrictions: requiring states to reject proof of frailty if the diagnosis is more than a year old, and allowing states to accept only one self-attestation per continuous enrollment period. He said the government provided a "non-frivolous rationale" for those provisions and explained why it did not find the states' concerns of disenrollment compelling.
Representatives from the Department of Health and Human Services and CMS did not immediately respond to an Associated Press request for comment.
The work requirements are part of Trump's 2025 tax and policy law. Starting Jan. 1, expansion enrollees aged 19 to 64 must show they work or do community service at least 80 hours a month, or are in school at least half the time. Exceptions exist for those considered medically frail or in addiction treatment, among others.
Analysis
Why This Matters
- The ruling eases access to medically frail exemptions for chronically ill Medicaid enrollees in 25 states and DC, potentially preventing loss of coverage for many.
- It leaves the underlying work requirements intact, so states must still implement verification for other enrollees, affecting program administration and beneficiary outreach.
- The case shows how courts are shaping implementation of the 2025 law's Medicaid changes, a key part of the broader policy debate.
Background
The "One Big Beautiful Bill" added work requirements for Medicaid expansion enrollees aged 19 to 64. The law defined medically frail categories, but CMS guidance imposed an additional "significantly impair" test for those categories. A coalition of states challenged that guidance as exceeding the law's text. Judge Stearns' ruling sets a precedent on how strictly states can verify frailty.
Key Perspectives
- Plaintiff states and DC: argued the stricter rule would prevent eligible Americans from accessing needed care and oversteps the law's text.
- Judge Richard Stearns: said states showed irreparable harm from costly verification system changes, but also found the government's rationale for the other two restrictions "non-frivolous."
What to Watch
- Whether the administration appeals the ruling or revises the CMS guidance to conform.
- How states adjust their eligibility verification systems before the Jan. 1 start of work requirements.
- Whether further court challenges target the work requirements themselves, which were not struck down.
Checked
12 claims in this story checked against 1 source: 12 supported.
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- SupportedA federal judge blocked an extra Medicaid work-rule test for frailty exemptions.OPB: “the CMS rule went further, requiring people in those categories to show that their conditions also “significantly impair” their ability to comply with the law’s work requirements.”
- SupportedThe ruling is partial: states prevailed against one condition but not two other restrictions.OPB: “Additionally, Stearns upheld two other federal restrictions on how states can verify medical frailty”
- SupportedStearns said the government provided a “non-frivolous rationale” for the provisions it upheld.OPB: “Stearns said “the government provided a non-frivolous rationale for adopting each provision and explained why it did not find the States’ concerns of disenrollment compelling.””
- SupportedA coalition of 25 states and the District of Columbia received a partial victory.OPB: “U.S. District Judge Richard Stearns in Boston gave a partial victory to a coalition of 25 states and the District of Columbia”
- SupportedThe CMS guidance required people in the law’s medically frail categories to show their conditions significantly impair their ability to comply with work requirements.OPB: “requiring people in those categories to show that their conditions also “significantly impair” their ability to comply with the law’s work requirements.”
- SupportedStearns ruled Thursday in Boston that states need not apply the stricter test for medically frail exemptions.OPB: “Chronically ill people on Medicaid won’t be bound by new work requirement rules that the latest Trump administration guidance requires in order to qualify for “medically frail” exemptions, a federal judge ruled Thursday.”
- SupportedThe coalition sued in June over CMS guidance linked to the 2025 One Big Beautiful Bill.OPB: “which sued the Trump administration in June over the new Centers for Medicare and Medicaid Services guidance linked to the 2025 law known as the “One Big Beautiful Bill.””
- SupportedThe law’s medically frail definition includes the listed categories of people and conditions.OPB: “The law says the definition of medically frail must include people who are blind or disabled, have substance use disorders or disabling mental disorders, have certain disabilities that significantly impair daily activities, or have serious or complex medical conditions.”
- SupportedStearns found the states had shown irreparable harm that monetary damages would not adequately compensate, citing costly and intensive eligibility-system changes.OPB: ““The states have met their burden of showing irreparable harm for which monetary damages would provide inadequate compensation — they face the burden of costly and intensive alterations to their eligibility verification systems,” Stearns said in his 16-page ruling.”
- SupportedThe ruling does not strike down the work requirements themselves.OPB: “Stearns’ decision does not strike down the work requirements as unlawful.”
- SupportedStearns upheld the restriction requiring states to reject proof of frailty when the diagnosis is more than a year old.OPB: “including the requirement that states reject proof of patients’ medical frailty if the diagnosis is more than a year old.”
- SupportedStearns upheld the restriction allowing only one self-attestation per continuous enrollment period.OPB: “He also upheld a policy allowing states to accept only one self-attestation per continuous period of enrollment.”