Judge Blocks Medicaid Rule That Required Seriously Ill Enrollees to Prove They Cannot Meet Work Requirements

A federal judge in Boston on Thursday blocked part of a Trump administration rule that would have narrowed who counts as “medically frail” under new Medicaid work requirements, ruling that the Centers for Medicare and Medicaid Services (CMS) went beyond what Congress wrote into law.

U.S. District Judge Richard Stearns in Boston sided with 25 states and the District of Columbia, which sued in June over CMS guidance tied to the One Big Beautiful Bill Act, the 2025 tax and spending law that created the first federal work requirement in Medicaid.

Under that law, most adults ages 19 to 64 covered through the Medicaid expansion must complete 80 hours of work or community service each month, or attend school at least half time, starting January 1, 2027. Congress exempted people who are “medically frail or otherwise have special medical needs.”

What the rule added, and what the judge struck down

CMS issued its rule in June to tell states how to run the program. For the exemption, the rule said a person qualified only if a physical, mental, or other behavioral health condition “significantly impairs” the person’s ability to meet the work requirement.

Stearns ruled that the added test was unlawful. The law says the definition of medically frail must include people who are blind or disabled, people with substance use disorders or disabling mental disorders, people with certain disabilities that significantly impair daily activities, and people with serious or complex medical conditions, according to CNN and Reuters. The judge held that CMS could not require people in those groups to clear a second hurdle.

“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.

The ruling was only a partial win for the states. Stearns upheld two other parts of the rule the states had challenged: states must reject proof of medical frailty based on a diagnosis more than a year old, and states may accept only one self-attestation per continuous period of enrollment. He wrote that the government gave a “non-frivolous rationale” for each of those provisions.

What happens next for enrollees

CMS declined to comment, according to CNN. It is not yet clear whether the administration will appeal. The January 1, 2027 start date for the work requirements has not changed, and some states, including Nebraska and Montana, have already started enforcing the mandate, CNN reported.

Morgan Henderson, an economist who studies Medicaid at the Hilltop Institute at the University of Maryland, Baltimore County, told CNN the ruling could preserve coverage for people who are sick but would not have met the stricter test. “Those individuals who would have lost coverage because they’re sick but they’re not quite sick enough,” he said, “they might have their coverage preserved now.”

North Carolina Health and Human Services Secretary Dr. Dev Sangvai said in a statement that the decision would help patients avoid stressful paperwork and fear of losing coverage during treatment. The Congressional Budget Office estimated last summer that 5.3 million more people would be uninsured in 2034 because of the work requirement, according to CNN.

Medicaid is the government health insurance program for low-income Americans, jointly funded by the federal government and the states. For the basics on how the program compares with subsidized private plans, see how Medicaid and Marketplace coverage differ.

Reporting based on coverage by CNN and Reuters.