Federal Judge Deals the Trump Administration a Major Blow Over Severe Medicaid 'Medically Frail' Limits

Federal judge Richard Stearns has struck down the Trump administration's strict new definition of 'medically frail' for Medicaid recipients, ruling that officials unlawfully limited exemptions from work requirements for chronically ill people in a case brought by 25 states and the District of Columbia.

The Boston ruling, issued on Thursday, targets a June regulation implementing the One Big Beautiful Bill Act, enacted in 2025. The law introduced work requirements for certain low-income adults covered through the Affordable Care Act's Medicaid expansion, while exempting people considered medically frail.

The decision affects how medical frailty is defined and applied. The wider work requirements are still due to take effect nationwide in January.

Under the statute, affected recipients must complete 80 hours a month of work or volunteering, or attend school at least half-time, to retain their benefits unless they qualify for an exemption.

Medicaid Definition Exceeded Congress's Terms

Stearns, a Clinton appointee, concluded that the Centers for Medicare & Medicaid Services had exceeded what Congress authorised, finding its rule 'thus contrary to law'.

For people seeking a medical exemption, the dispute centred on the distinction between having a diagnosed condition and proving that it prevents work. The states challenged the administration's insistence on the latter.

'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,' he stated. 'There is an inherent public interest in ensuring that the government follows the law.'

During oral arguments the previous week, the states had sought permission to grant exemptions for people with certain diagnosed conditions. They warned that leaving the restriction intact before January would oblige them 'to bear the costs and burdens of operationalizing this unlawful limitation'.

The ruling also grants the plaintiff states a six-month stay of enforcement covering medical-frailty determinations, allowing time to adjust their verification systems. That protection gives states a transition period to prepare the verification systems needed to administer the policy.

Medicaid Records Face a 12-Month Limit

The states did not prevail on every issue. Stearns upheld CMS's restriction on relying on claims and encounter data more than 12 months old, including hospital admission records, to establish medical frailty.

The coalition argued that this could lead to further losses of coverage because medically frail patients might not require major health services for more than a year.

Stearns determined that the agency had a rationale for the 12-month period and rejected the argument that it was arbitrary.

'That the states (or even the court) may disagree with the wisdom of the agency's policies and conclusions, or may have made different choices, is irrelevant,' he wrote.

State Discretion Over Medicaid Declarations

Stearns also upheld the administration's decision to let states choose whether to accept a patient's own declaration of being too ill to work during the first year of the requirements.

Accepting such declarations would allow recipients to establish their condition without medical documentation at that stage. The coalition had argued that every state should be required to accept them. Eight states have already opted to require documentation in 2027, arguing that self-attestation creates opportunities for fraud.

From 2028, states may accept one self-attestation of medical frailty per continuous enrolment period, but must verify the condition through electronic data or documentation at the recipient's next renewal.

A federal court in Maryland is still considering a separate challenge brought by the city of Columbus, Ohio, and several medical groups.