US judge strikes down CMS's narrow 'medically frail' definition for Medicaid work requirements

Judge Richard Stearns of the US District Court for the District of Massachusetts ruled on 29 October that the CMS definition was narrower than Congress intended in the 2025 budget law, Healthcare Dive reported. He vacated it and granted the permanent injunction that 25 states and the District of Columbia had asked for when they sued in June.

The law requires adults covered through the Affordable Care Act's Medicaid expansion to log at least 80 hours a month of work, volunteering or study from 2027. People who are medically frail are exempt. The CMS rule issued this summer limited that exemption to people with serious or complex conditions who were too sick to comply, and critics said many very ill enrollees would fall outside it. The judge wrote that enforcing an unlawful definition could lead to eligible, vulnerable people being removed from Medicaid.

Stearns upheld two other provisions that the states had challenged. States may use only the previous 12 months of claims and clinical visit data to decide frailty, and limits on how often people can self-attest remain. He gave states a six-month stay on enforcing frailty determinations so they can adjust their processes.

A CMS spokesperson declined to comment because the case is pending, and the agency can still appeal. A separate suit by enrollees and provider groups that challenges the work requirements themselves has not been decided. Families USA, a consumer group, asked the administration to delay the requirements, which it said start in two months.