Judge Strikes Down CMS Definition of 'Medically Frail' in Medicaid Rules

A federal judge in Boston ruled Thursday that the Centers for Medicare and Medicaid Services went beyond the statute when it narrowed who qualifies as "medically frail" for exemptions from Medicaid work requirements, siding with 25 states and the District of Columbia and blocking the guidance from being enforced. U.S. District Judge Richard Stearns called the agency's reading "contrary to law" in a 16-page order that leaves the work requirements themselves intact.

The requirements begin Jan. 1, 2027 for adults ages 19 to 64 covered through the Medicaid expansion, who must document at least 80 hours a month of work, community engagement or half-time schooling, unless they fall into an exempt category. Being medically frail is one of those categories. So is being in addiction treatment.

What the guidance added to the law

The 2025 law known as the One Big Beautiful Bill Act specified who the frailty definition must cover: people who are blind or disabled, people with substance use disorders or disabling mental disorders, people whose disabilities significantly impair daily activities, and people with serious or complex medical conditions. CMS issued guidance in June telling states how to apply that list.

The guidance added a second test. People in those categories would also have to show that their conditions "significantly impair" their ability to comply with the work requirements — a determination that would be made through state eligibility systems rather than by the clinician treating them.

The ruling, and what it left standing

Stearns found that the states had shown the kind of harm that an injunction is meant to prevent. "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.

His order also addressed the administrative side of the problem the states raised: "The states have met their burden of showing irreparable harm for which monetary damages would provide inadequate compensation — they face the burden of costly and intensive alterations to their eligibility verification systems."

The decision is narrower than a full rebuke of the administration. Stearns declined to strike down the work requirements, and he upheld two other CMS restrictions that the states had challenged: a rule requiring states to reject proof of frailty when the supporting diagnosis is more than a year old, and a policy allowing only one self-attestation per continuous period of enrollment. On those provisions he wrote that the government had offered "a non-frivolous rationale" and had explained why it did not find the states' disenrollment concerns compelling.

CMS and the Department of Health and Human Services did not respond to a request for comment from the Associated Press.

Why the addiction category carried the case

Substance use disorder is not an incidental item on the statutory list — it is one of four groups Congress named explicitly, alongside disabling mental illness. Under the June guidance, a person with an opioid use disorder would have had to establish that the disorder significantly impaired their capacity to hit an 80-hour monthly threshold, even though the law had already placed that person in an exempt category. Recovery is also cyclical in ways that fit badly into eligibility systems built around continuous verification: a relapse, a residential stay, or a gap in documentation can look like noncompliance from the state's side of the file.

The separate exemption for people enrolled in addiction treatment programs remains in the statute and was not at issue in Thursday's ruling. The practical difficulty is that exemptions have to be claimed and verified, and the population most likely to lose coverage is the one least able to produce paperwork on a deadline — which is the harm the states described to the court.

Thursday's decision does not resolve the larger fight over whether the work requirements can be implemented on schedule. It changes who has to prove what in the meantime. People who are already navigating state verification systems, including Hoosiers told by Indiana that they fall short of the rules, face the same January deadline regardless of the ruling's scope.

The implementation clock

States have been building the verification infrastructure for more than a year, and the order itself acknowledges the scale of that work: the judge described costly and intensive alterations to eligibility systems that states would have to absorb. The injunction relieves them of one filter — a frailty test that the judge found unlawful — without giving them more time. Whether states now widen exemptions on their own, or wait for further litigation, will determine what the ruling means in practice for a person with a substance use disorder who is working twenty hours a week, attending outpatient treatment three evenings a week, and has to prove both to a portal by spring.

Patients can find medication-assisted treatment programs and information on substance use disorder independent of how a state administers its Medicaid exemptions.