October 30, 2026

3 min read

Key takeaways:

  • People who fall under a medical frailty category will not have to demonstrate their condition impairs their ability to meet work requirements.
  • The ruling does not overturn the broader Medicaid work requirements.

A federal judge struck down a CMS rule requiring Medicaid beneficiaries with qualifying medical conditions to prove they cannot meet new work requirements.

The order does not overturn the broader Medicaid work requirements enacted under H.R.1, or the One Big Beautiful Bill.



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People who fall under a medical frailty category will not have to demonstrate their condition impairs their ability to meet work requirements. Image: Adobe Stock

Starting Jan. 1, certain Medicaid beneficiaries aged 19 to 64 years will be required to engage in qualifying activities — employment, community service or some work programs — for 80 hours per month, or make at least $580 monthly (the minimum wage multiplied by 80 hours), “or be enrolled in educational program for at least half time,” according to CMS.

Individuals who fall within one of the following medical frailty categories will be exempt from the work requirements:

  • being blind;
  • having a substance use disorder;
  • having a disabling mental disorder;
  • having a physical, developmental or intellectual disability that interferes with activities of daily living; or
  • having a serious or complex medical condition.

In June, CMS added a stipulation that would have required beneficiaries with qualifying medical conditions to demonstrate that their condition significantly impairs their ability to meet the work requirements.

In Commonwealth of Massachusetts v. Oz, 25 states and Washington, D.C., argued that this additional rule “unlawfully narrowed the medical frailty exemption Congress established,” according to an AMA press release.

The AMA, along with 10 other medical societies, had filed an amicus brief in the case on Sept. 10, which argued the change “could cause eligible patients to lose Medicaid coverage,” a press release said.

U.S. District Judge Richard G. Stearns, JD, ruled that CMS could not impose an impairment test on beneficiaries who meet the medical frailty categories

CMS ‘lacked authority’ for definition

Stearns wrote in the order that CMS “lacked authority to exclude any subset of individuals” within the five categories.

“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 order upholds CMS’ work requirement and a requirement that states reject proof of patients’ medical frailty if the diagnosis is over a year old. It also allows states to accept just one self-attestation every continuous period of enrollment.

Stearns explained the states’ arguments against these were “unconvincing and falling well short of the arbitrary or capricious standard under the” Administrative Procedures Act.

“The government provided a non-frivolous rationale for adopting each provision and explained why it did not find the states’ concerns of disenrollment compelling,” he wrote.

‘A victory for patients’

The ruling “is a victory for patients as it strikes back against unnecessary barriers to care,” AMA President Willie Underwood III, MD, MSc, MPH, said a statement.

“The court rightly rejected a federal restriction that would have made it harder for people with serious or complex health conditions to qualify for an exemption from Medicaid work requirements,” Underwood III said. “Patients should not have to clear unnecessary bureaucratic hurdles to keep their health coverage, especially hurdles that go beyond what Congress intended.”

The ruling would have adversely impacted eligibility, Underwood III argued, because a patient’s condition may not always fit the agency’s definition at every point in time.

“Symptoms can fluctuate. Treatment can be debilitating. A person may be able to work at one point but be unable to manage the demands of work at another,” he said.

Underwood III added the ruling would have further created additional administrative burden for clinicians — requiring them to determine if a patient’s condition would impair their ability to comply with work requirements, which “is time taken away from patient care” — while affecting physician-patient relationships by dissuading patients from discussing pain, fatigue, mental health issues and substance use “if they fear those conversations could affect their coverage.”

“CMS should stop putting barriers between medically frail patients and the care they need,” he said. “Physicians should spend their time treating patients, not proving that those patients deserve to keep their Medicaid coverage.”

Sources/Disclosures

Source:


Press Release

References:


Disclosures:
Healio could not determine relevant financial disclosures at the time of publication.

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