Judge blocks CMS test requiring Medicaid enrollees to prove frailty impairs work

A Medicaid agency in the states that sued can no longer make an adult prove that a qualifying illness also keeps them from meeting the new work requirement before granting the medically frail exemption. U.S. District Judge Richard Stearns in Boston ruled Thursday, October 29, that the Trump administration cannot enforce that extra test, because Congress never wrote it into the law. Reports on the order did not say whether it reaches beyond the 25 states and the District of Columbia that brought the case, which had asked for relief covering only themselves.

The sentence CMS added

The 2025 reconciliation law requires states to condition Medicaid expansion coverage on work or community engagement for adults ages 19 to 64, at 80 hours a month, with an exemption for people who are medically frail or have special medical needs. The statute lists who counts: people who are blind or disabled, people with a substance use disorder or a disabling mental disorder, people with a physical, intellectual or developmental disability that limits daily activities, and people with a serious or complex medical condition. KFF, which analyzed the rule when it came out on June 1, found that CMS then asked states to apply a second question to everyone on that list.

The rule, codified at 42 CFR 435.554(c)(5)(i), says the exemption applies only when the condition "significantly impairs the individual's ability to comply with the community engagement requirement." For serious or complex conditions, KFF reported, the rule also demands a "severe level of acuity." Andy Schneider of the Georgetown Center for Children and Families wrote in July that the rule "imposes policies on states and individuals that the Congress did not enact."

Stearns, a Clinton appointee, agreed in a 16-page opinion, according to the Associated Press. He wrote that enforcing the narrower definition "may lead to the disenrollment of otherwise eligible vulnerable individuals," and that without an injunction the states and the public face "great hardship."

What the judge left standing

The government did not lose everything. The statute tells the HHS secretary to define medical frailty, which is the footing CMS stands on, and Stearns upheld two of the verification rules the states had challenged. States may reject proof of frailty built on a diagnosis more than a year old, and they may accept only one self-attestation of frailty per continuous enrollment period. Under the rule as KFF describes it, states must pull claims or encounter data from the previous 12 months, may rely on self-attestation through 2027 when no reliable records exist, and may accept it only once from January 1, 2028.

On those provisions the judge said the government offered a non-frivolous rationale for each and that the states' worries about disenrollment were not compelling, the AP reported. In practice the exemption survives with the statutory categories intact and the paperwork rules tight.

How the same judge got from July to October

Stearns denied the states a preliminary injunction in late July. Reporting from AJMC at the time said he did so largely because the states' implementation costs were not shown to be irrecoverable, and because CMS had committed to reimburse 90 percent of the cost of designing, building and installing eligibility systems. That ruling was no verdict on the merits.

The October order reads the harm differently. The AP reported that Stearns found the states face "costly and intensive alterations to their eligibility verification systems," and STAT reported he concluded they lacked the time and resources to rebuild those systems by the deadline. California, Massachusetts and New Jersey attorneys general led the suit, filed at the end of June as Commonwealth of Massachusetts v. Oz, No. 1:26-cv-12962. The defendants are CMS Administrator Mehmet Oz, Health Secretary Robert F. Kennedy Jr. and their agencies.

This account rests on news coverage of the opinion and on the rule text as reproduced by KFF and Georgetown, not on the 16-page order itself, which was not available to read. The law requires 44 states to impose work requirements starting January 1, 2027, and no estimate of how many enrollees the frailty definition affects appeared in the sources reviewed. CMS and HHS had not responded to requests for comment from the AP or NBC News, and none of the reports said whether the government will appeal.