A federal judge in Massachusetts has struck down the Centers for Medicare & Medicaid Services’ definition of “medically frail” used to exempt Medicaid enrollees from upcoming work requirements, a decision that could reshape how states assess eligibility while leaving other parts of the rule intact.
Judge vacates narrow exemption definition
U.S. District Judge Richard D. Stearns ruled that the CMS definition, which limited exemption to individuals so ill they could not meet work, volunteering or schooling thresholds, goes beyond what Congress intended under the so-called “Big Beautiful Bill.”
The judge issued a permanent injunction against the definition and granted states a six-month stay before the revised standards take effect, though the agency may appeal the order.
Medicaid work requirements and the “Big Beautiful Bill”
The Republican-backed law, enacted last summer, requires adults receiving Medicaid through the ACA expansion to log at least 80 hours of work, volunteering or schooling each month to stay eligible starting in 2027. The law excluded people who are blind or disabled, along with those with a substance use or serious mental health disorder; a physical, intellectual or developmental disability that impairs daily living; or a serious or complex medical condition. The legislation, commonly referred to as the “Big Beautiful Bill,” was passed with a narrow majority and aims to encourage employment among Medicaid recipients.
States, pressed to implement the mandates, initially relied on informal CMS guidance to identify which enrollees with a serious or complex condition qualified for an exemption. In summer, CMS issued formal guidance that tightened the exemption, requiring a level of illness that prevented compliance with the work rules.
The stricter rule sparked backlash because it added a burden on sick beneficiaries to prove they were too ill to work, raising concerns that vulnerable patients could lose coverage.
Legal challenge and court’s reasoning
In June, a coalition of 25 states and the District of Columbia sued, arguing that the medical frailty definition exceeded the statutory language. The plaintiffs contended that Congress intended a broader exemption for those with serious medical conditions, not only the most severely ill.
Judge Stearns rejected the states’ request for an immediate pause on the work requirements in July but later agreed that the added limitation “deviated from Congress’ intent.” He wrote that enforcing an unlawful definition could disenroll eligible vulnerable individuals, creating “great hardship” for the public.
While the judge nullified the frailty definition, he left two other contested provisions untouched: states may use only medical claims and clinical visit data from the past 12 months—rather than a full medical history—to assess exemption, and limits on how often individuals can self-attest to their condition remain.
Response from health organizations and advocates
Provider groups welcomed the decision. Susan Dentzer, president and CEO of America’s Physician Groups, called the ruling “a victory for the rule of law, medical ethics, and common sense.”
Dr. Willie Underwood, president of the American Medical Association, described the outcome as “a victory for patients,” noting that the AMA had filed an amicus brief supporting the states.
Families USA, a consumer-advocacy organization, urged the administration to postpone the work-reporting requirements, arguing the court’s decision provides a “welcome reprieve” amid ongoing uncertainty.
Practical impact on state Medicaid programs
States now have to redesign their processes for determining who qualifies for the exemption without the narrow definition. The six-month stay gives agencies time to adjust data systems and develop new criteria that align with the broader statutory language.
Future litigation and political context
CMS has declined comment, citing pending litigation, and retains the option to appeal. Additional lawsuits are pending, including a case filed by Medicaid enrollees and provider groups challenging the work-requirement rule itself. The agency indicated that it will continue to monitor the implementation while the courts consider the challenges.
States are also bracing for potential policy shifts if the balance of power changes in next week’s midterm elections. Democrats are expected to retake control of the House, which could spark an effort to overturn work requirements altogether.
