People with certain serious illnesses, disabilities or substance use disorders cannot be required to prove that their conditions prevent them from meeting Medicaid's work requirements to qualify for a medical exemption, a federal judge ruled on Thursday 29 October.

US District Judge Richard Stearns in Boston found that the Centers for Medicare & Medicaid Services (CMS) overstepped its authority. It had demanded proof that a condition 'significantly impairs' a person's ability to meet the work rule.

The ruling is a partial win for 25 states and the District of Columbia, which sued in June. It does not strike down the work requirement itself, and two paperwork limits on proving frailty remain.

Five Frailty Categories Protected

Federal law exempts people who are medically frail or have special medical needs from the new Medicaid work rule. The law says the definition must include five groups, and the agency could not exclude anyone within them. They are:

  • People who are blind or disabled
  • People with a substance use disorder
  • People with a disabling mental disorder
  • People with a physical, intellectual or developmental disability that significantly impairs one or more activities of daily living
  • People with a serious or complex medical condition

The word 'including' in the law was read as a floor, not a ceiling. Anyone within the five categories qualifies as medically frail without having to prove that their condition prevents them from meeting the work requirement. However, Congress retained a separate functional limitation for people with physical, intellectual or developmental disabilities, requiring their condition to significantly impair at least one activity of daily living.

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Paperwork Rules the Judge Upheld

The court left two other parts of the rule in place. States must reject proof of medical frailty drawn from claims and encounter data older than 12 months before an application. Each limit was backed by a non-frivolous rationale from CMS.

States may also accept only one self-attestation, a patient's own statement of frailty, per period of enrolment. That period is a continuous stretch of coverage without disenrolment, regardless of renewals or moves between eligibility groups.

The rule also bars states from denying frailty status because claims data are missing or lagging. That matters for patients with a recent diagnosis whose care has not yet shown up in the records.

Work Requirement Start Date Stands

The order does not strike down the work requirement. Most adults aged 19 to 64 covered by the Medicaid expansion must still complete 80 hours of work or community service each month, or attend an educational programme at least half-time, beginning 1 January 2027.

The court also granted states a six-month stay of enforcement concerning determinations of whether individuals qualify as medically frail, giving them time to update their eligibility verification systems.

The stay does not move the 1 January 2027 deadline set by Congress. The states made clear at a hearing on 22 October that they did not seek to delay it.

Effect on Patients and States

Morgan Henderson, a Medicaid economist at the Hilltop Institute at the University of Maryland, Baltimore County, said the ruling is likely to help some people obtain or keep coverage. He cited people who are sick but 'not quite sick enough'.

North Carolina Health and Human Services Secretary Dev Sangvai said the decision would help patients avoid confusing paperwork and the fear of losing coverage during treatment. North Carolina is among the states that brought the challenge.

The judge struck the added language and issued a permanent injunction against it. Enforcing the unlawful definition may lead to the disenrolment of otherwise eligible, vulnerable people who rely on Medicaid for continuity of care.

California Attorney General Rob Bonta said in a statement that people with serious illnesses or disabilities should not have to worry about losing healthcare because of work requirements. 'That's not what Congress intended.' CMS declined to comment.

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