Judge blocks Medicaid frailty test in 25 states and D.C.

A federal judge on Thursday blocked a federal rule that would have made sick and disabled Medicaid enrollees in 25 states and the District of Columbia prove their condition keeps them from working. U.S. District Judge Richard Stearns in Boston ruled that the Centers for Medicare & Medicaid Services could not narrow a definition Congress already wrote.

The work requirement itself survives. Starting Jan. 1, 2027, most Medicaid adults ages 19 to 64 must log at least 80 hours a month of work, volunteering or school to keep coverage, Reuters reports. What changed is who gets out of it.

What the rule said

The 2025 tax and spending law, the One Big Beautiful Bill Act, exempts people who are “medically frail or otherwise have special medical needs.” Congress said that group includes people who are blind or disabled, people with certain mental disorders and people with complex medical conditions, according to Courthouse News Service.

CMS issued a rule in June that added a second test. A person in that group qualified only if their “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply” with the work requirement, Reuters reports.

So a person with cancer or a serious mental illness could still lose the exemption unless they showed the illness stopped them from meeting the 80 hours.

What the judge decided

Stearns granted summary judgment to the states in a 16 page order, Courthouse News reports. He found the CMS definition “contrary to law” because Congress had already defined the term.

The court vacated the added language, issued a permanent injunction and gave the states a six month stay of enforcement to fix their systems, the California attorney general’s office said.

“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.

He also found the states would face “costly and intensive alterations to their eligibility verification systems” if the rule stood, Courthouse News reports.

What the states did not win

The ruling was partial. Stearns upheld other parts of the rule the states had challenged, Reuters reports. The work requirement and its Jan. 1, 2027 start date are untouched.

The states sued in June. California, Massachusetts and New Jersey led the challenge, according to Reuters. New York Attorney General Letitia James joined with 24 other states and the District of Columbia, her office said.

“New Yorkers who are living with cancer, a disability, a serious mental health condition, or addiction should never have to prove they are sick enough to keep their health care,” James said in a statement.

CMS does not comment on pending litigation, Courthouse News reports. The Department of Health and Human Services did not immediately respond to that outlet.

What it means for you

If you get Medicaid in one of the states that sued, the stricter frailty test is off for now. Under the law’s own terms, a disability, a serious mental health condition or a complex medical condition can qualify you for the exemption without a second showing that you can’t work.

You still have to claim the exemption through your state. Ask your state Medicaid office how it will handle frailty claims before the January start.

The states argued the stricter test would hit older adults not yet old enough for Medicare and people with serious chronic conditions hardest. In their June complaint, they warned it would push more people into uncompensated emergency care and make rural hospitals more likely to close, Courthouse News reports.