In a ruling on Thursday, a federal judge in Boston ruled for the District of Columbia and a 25-state coalition in their suit against the Trump administration’s requirement that Medicaid recipients with chronic illnesses prove they cannot work.
At oral arguments the previous week, the states warned that if the court did not put a stop to the rule before January and allow them to make exceptions for those with certain diagnosed conditions, they would have “to bear the costs and burdens of operationalizing this unlawful limitation.”
Richard Stearns, a Clinton appointee, found that the June rule from the Centers for Medicare & Medicaid Services was “thus contrary to law” because it went beyond what Congress had included in the One Big Beautiful Bill Act in 2025.
“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 said, according to Politico. “There is an inherent public interest in ensuring that the government follows the law.”
Under the One Big Beautiful Bill Act, many Medicaid recipients must put in 80 hours a month of work or volunteering, or attend school at least half-time, to hold on to their benefits. This applies to certain low-income adults who get Medicaid through the Affordable Care Act’s expansion, except those who qualify for exemptions, including people considered medically frail.
The ruling also gives the states time to put their verification systems in order, with a six-month period of protection from penalties for implementation errors or delays. The decision only puts the brakes on the “medical frailty” part of the rule; the remainder of the work requirements will go into effect across the country in January.
CMS did not immediately respond to a request for comment, according to Reuters.
Stearns was not swayed by the states on other points of the rule. He upheld the government’s position on restricting the use of medical records, such as hospital admission records, older than 12 months to verify a patient’s medical frailty.
The states had argued that such a provision would result in more disenrollments since a medically frail person might not need major health services for over a year.
The judge determined CMS had a rationale for the 12-month “lookback” period and that it was not arbitrary, as the states had argued.
“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.
He likewise sided with the Trump administration on its policy of allowing states to decide whether to take a patient’s word for being too ill to work instead of requiring medical documentation during the first year of the requirements.
From 2028 onward, Medicaid expansion recipients can self-attest once but must provide further evidence of their condition at the next renewal.
Eight states have already rejected the grace period and will require documentation in 2027, arguing that self-attestation opens the door to fraud. In their case, the states contended that the administration should have required all states to accept it.
A Maryland federal court is still considering a separate challenge to the policy brought by the city of Columbus, Ohio, and several medical groups.
