A federal judge in Boston on Thursday, October 29, struck down part of the Trump administration's rule for the new Medicaid work requirement, ruling that the government had narrowed the "medically frail" exemption beyond what Congress allowed. People who are blind or disabled, have a substance use disorder, have a disabling mental disorder, or have a serious or complex medical condition qualify for the exemption without also proving their condition keeps them from meeting the work rule.
The work requirement itself still starts January 1, 2027; the ruling changes who can be excused from it.
What the court decided
Congress wrote the requirement into the 2025 budget law, H.R. 1. It applies mainly to adults covered under the Affordable Care Act's Medicaid expansion, who will need to log 80 hours a month of work or community service, or be enrolled in school at least half-time, to keep coverage. The law exempts anyone who is "medically frail" and lists five groups the term includes.
The interim final rule the Centers for Medicare & Medicaid Services published in June added a condition: a person in one of those groups counted as medically frail only if the condition "significantly impairs" their ability to meet the requirement.
Judge Richard G. Stearns held in his memorandum and order that the agency had no authority to add that test. He noted that Congress attached a functional test to only one of the five groups: people with a physical, intellectual or developmental disability must show it significantly impairs at least one activity of daily living. He also cited Rep. Brett Guthrie's statement at the time that the exemption covers "anyone who's blind, disabled, battling a chronic substance-use disorder or living with a serious and complex medical condition like cancer."
| Part of the CMS rule | Court's decision |
|---|---|
| Extra test that a condition must impair the ability to meet the work requirement | Unlawful. Removed from the rule, and its enforcement permanently barred |
| Medical frailty checked only against claims and encounter data from the past 12 months | Upheld |
| One self-attestation of medical frailty per enrollment period | Upheld |
What it means for enrollees
Someone in one of the five groups qualifies on the condition alone, without a separate finding about whether it keeps them from meeting the work rule. States can still check only the past 12 months of claims records to verify frailty, though, and a person can rely on their own statement just once per continuous enrollment period, so recent medical records still matter.
The judge also gave states a six-month stay of enforcement covering their decisions on who does or does not qualify as medically frail, to allow for errors or delays while they change their eligibility systems on a short timeline. He wrote that the stay does not move the January 1 start date, which the states did not ask to change and which he said the court could not change anyway.
Who sued
Twenty-three states and the District of Columbia brought the case in June, joined by the governors of Kentucky and Pennsylvania. Massachusetts is the lead plaintiff. California Attorney General Rob Bonta announced the decision Thursday. The defendants are CMS, its administrator Mehmet Oz, Health and Human Services Secretary Robert F. Kennedy Jr. and HHS. The court documents do not say whether the government will appeal.
