Federal judge rules CMS’ definition of ‘medically frail’ unlawful
After ruling in July against a coalition of 26 states seeking a preliminary injunction against the implementation of Medicaid work requirements as outlined by the Centers for Medicare & Medicaid Services (CMS), the same judge has now struck down the agency’s definition of “medically frail,” acquiescing to the request of the plaintiffs.
The issue around defining what makes a patient medically frail in a legal sense, thus exempt from work and school requirements for Medicaid eligibility, has been a central complaint of the states, who believe the definition from CMS to be subjective and unenforceable, inevitably pushing people with serious medical coverage needs off the safety-net program.
U.S. District Court of Massachusetts Judge Richard Stearns said CMS is not complying with the will of Congress, which established the Medicaid Work Requirements as part of the 2025 One Big Beautiful Bill Act.
While CMS describes the medically frail exemption as applying to any patient whose “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement,” Stearns said that five criteria established by Congress were missing under the rule established by the Trump administration.
“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," He wrote.
“The court accordingly will issue the permanent injunction requested by the States.”
He recommended that CMS issue a six-month pause on the requirement to report the identities of medically frail Medicaid beneficiaries, until the details can be ironed out. The rollout is expected to begin at the beginning of 2027, though is now partially paused due to the court’s ruling.
The Medicaid work requirements were not struck down. They will still go into effect as planned on Jan. 1.
A nuanced decision
Stearns had previously rejected an argument from the plaintiffs who argued they were damaged by the administrative burden of implementing the work restrictions, given the limited time frame.
CMS outlined how the law will be enforced in June, giving states less than seven months to comply.
The states—which in addition to the primary plaintiffs include Arizona, Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Kentucky, Maine, Maryland, Michigan, Minnesota, Nevada, New Mexico, New Jersey, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington and Wisconsin—argued that they lacked the resources necessary to enforce the terms CMS was imposing.
Stearns ultimately ruled that the states failed to show they would be irreparably harmed by adapting, opting not to issue a preliminary injunction.
CMS will need to respond to the ruling on the medically frail rule being unlawful, either by appealing or changing the policy.
In a related move, five states penned an open letter this month to the U.S. Department of Health and Human Services (HHS), asking Secretary Robert F. Kennedy Jr. to delay the enforcement of the Medicaid work requirements and requesting a "reasonable timeline” to develop systems and protocols to ensure exemptions are applied fairly.
A key sticking point in the request was CMS’ definition of medically frail.
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