Boston Federal Judge Strikes Trump Administration's Narrow 'Medically Frail' Test for Medicaid Work Rules and Gives States Six More Months

A federal judge in Boston on Thursday struck down a key part of the Trump administration's rule for new Medicaid work requirements, ruling that the government cannot make people who qualify as "medically frail" also prove that their condition keeps them from meeting the work requirement, according to the ruling as quoted in news reports.

U.S. District Judge Richard Stearns sided with 25 states and the District of Columbia, led by the attorneys general of Massachusetts, California and New Jersey, Reuters reported in a story published by NBC News. Stearns upheld other parts of the rule that the states had also challenged. The Centers for Medicare & Medicaid Services did not immediately respond to a request for comment, according to Reuters.

The case grows out of the federal tax and spending law President Donald Trump signed on July 1, 2025, known as the One Big Beautiful Bill Act. It requires most Medicaid adults ages 19 to 64 to complete at least 80 hours a month of work or community engagement, or be enrolled in school at least half time, to keep coverage beginning Jan. 1, 2027. The law exempts people who are "medically frail or otherwise have special medical needs."

Congress defined that group to include people who are blind, have a substance use disorder, have a serious mental disorder, have a "physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living," or have "a serious or complex medical condition," according to the ruling as described by Universal Hub.

CMS issued a rule in June to tell states how to carry out the law. It said the medically frail exemption applies only if someone's "physical, mental, or other behavioral health condition significantly impairs the individual's ability to comply with the community engagement requirement." The states argued that this added a second test that Congress never wrote, and would force eligible people to clear extra hurdles or lose coverage.

Stearns agreed. "In sum, the court agrees with the States that the agency lacked authority to exclude any subset of individuals in the five subcategories delineated as 'medically frail' by Congress, as the [proposed rule] purports to do," he wrote, according to the ruling as quoted by Universal Hub. The limiting language "is beyond the powers of CMS (ultra vires) and thus contrary to law," he wrote, and he ordered it removed from the rule.

The judge also explained why he acted now. "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," Stearns wrote, according to Reuters.

Because states now have to change their verification systems on a short timeline, Stearns gave them extra time. "[T]o accommodate any errors or delays which may arise given the short timeline under which the States must now change their verification systems, the court agrees that the States should receive a 6-month stay of enforcement as to any determination that an individual does or does not qualify as 'medically frail,'" he wrote.

In practical terms, the ruling does not stop the work requirement. It changes who must prove what. Under the decision, someone who documents that they fall into one of the five medically frail categories should be exempt without a separate showing that the condition prevents work, and states have six months of leeway on enforcement of medical frailty decisions while they rebuild systems.

For Massachusetts, that matters for MassHealth, the state's Medicaid program and the largest cost center in the state budget. The state Senate's supplemental budget released Thursday sends $1.8 billion to MassHealth to settle fiscal 2026 accounts. State officials have not yet said how many MassHealth members would fall under the work requirement or the medically frail exemption.

Stearns was appointed by former President Bill Clinton. The administration can appeal to the U.S. Court of Appeals for the First Circuit. Reuters reported that CMS did not immediately comment, and no appeal had been reported as of Friday.

Still unknown: whether the administration will appeal or seek a stay, and how MassHealth will change its exemption process before Jan. 1.