A Judge Blocked CMS's Narrower Medically Frail Test for Medicaid's Work Rule. The 12-Month Lookback Stands.
A judge ruled Oct. 29 that CMS cannot make frail Medicaid patients prove their illness impairs work. Records over 12 months old can still be rejected.
Idea in Brief
The News
On Oct. 29, U.S. District Judge Richard Stearns blocked the Centers for Medicare and Medicaid Services from enforcing its narrowed definition of "medically frail" in the Medicaid community engagement rule.
What Changes
Patients in the categories Congress listed, such as disabling mental disorders or serious and complex medical conditions, no longer also have to show the condition significantly impairs their ability to meet the work requirement, according to coverage of the ruling.
Why It Matters
The work requirement still starts Jan. 1, 2027. The 12-month documentation rule and the one-self-attestation limit survived, so current, specific chart documentation still decides many exemptions.
A federal judge in Boston on Oct. 29 blocked the Centers for Medicare and Medicaid Services (CMS) from enforcing its narrowed definition of who is "medically frail" under Medicaid's new work requirement, while upholding the rule's 12-month documentation limit.
The ruling, by U.S. District Judge Richard Stearns, is a partial win for the 25 states and the District of Columbia that sued in June. It does not stop the requirement itself. From Jan. 1, 2027, most adults ages 19 to 64 in the expansion group must show at least 80 hours a month of work or community engagement, or at least half-time schooling, to keep coverage, NBC News reported. The medically frail exemption is the part of that system that runs through the chart.
What did the judge block?
The extra impairment test. The 2025 law lists who counts as medically frail: people who are blind or disabled, people with a substance use disorder or a disabling mental disorder, people with a disability that significantly impairs activities of daily living and people with serious or complex medical conditions. CMS's interim final rule, published June 3, added a condition: the person's condition also had to "significantly impair" their ability to comply with the work requirement.
Stearns found that CMS went beyond the statute with that added condition, according to the Associated Press report carried by CT Mirror. He wrote that enforcing "an unlawful definition of 'medically frail'" may lead to "the disenrollment of otherwise eligible vulnerable individuals," STAT reported. He also found the states had shown irreparable harm because they "face the burden of costly and intensive alterations to their eligibility verification systems."
What did the judge leave in place?
Two provisions that matter to practices. Stearns upheld the part of the rule that lets states reject proof of frailty when the diagnosis or documentation is more than 12 months old, and the part that lets states accept only one self-attestation per continuous enrollment period, the AP reported. On those provisions, he wrote that "the government provided a non-frivolous rationale for adopting each provision." He did not rule the work requirement unlawful.
The Script Pad's reading of the coverage: the ruling widens who qualifies, but it does not lighten how often or how recently a qualifying condition has to be shown. A patient with schizophrenia or advanced heart failure no longer has to prove that the illness stops them from working 80 hours a month. The state can still ask for evidence from the past year, and the patient can still self-attest only once per enrollment period.
The definition got broader on Oct. 29. The paperwork clock did not. A diagnosis that has not been documented in the past 12 months may still not count.
Clinical Pearls
- Judge Richard Stearns of the U.S. District Court in Boston ruled on Oct. 29 in a 16-page decision, the Associated Press reported.
- The blocked provision required people in a medically frail category to also show the condition "significantly impairs" their ability to comply with the work requirement.
- The judge upheld letting states reject frailty documentation that is more than 12 months old.
- He also upheld letting states accept only one self-attestation per continuous enrollment period.
- The suit was brought by 25 states and the District of Columbia, led by California, Massachusetts and New Jersey, as reported by NBC News.
- Coverage of the ruling did not say whether the government will appeal. CMS declined to say, according to one report.
Who reacted, and what comes next?
The American Medical Association, the Massachusetts Medical Society and nine specialty societies had filed an amicus brief backing the states. "Today's decision is a victory for patients as it strikes back against unnecessary barriers to care," AMA President Willie Underwood III, MD, said in a statement on the ruling.
HHS and CMS did not immediately respond to requests for comment, and the reports did not say whether the government will appeal. The coverage also did not spell out whether the order reaches only the plaintiff states or every state, and we could not review the order itself, so practices in states outside the suit should check with their Medicaid agency. The same judge denied the states a preliminary injunction on July 29. A separate challenge brought by physician groups in Maryland federal court, which we covered on Oct. 18 was filed separately on Sept. 18.
What practices should do now
Ask your state Medicaid agency or managed care plans how they will apply the ruling before January, and whether their frailty screening still asks about ability to work. For patients in the listed categories, make sure the qualifying diagnosis appears in a visit, claim or note from the past 12 months, since older documentation can still be rejected. Our earlier piece on coding accuracy in the exam room applies directly: a specific, current code on a claim may be what keeps a patient from a manual review.
Reported, fact-checked and edited by The Script Pad's editorial staff. See How we use AI.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
