By Zachary Stieber
Contributing Writer
A federal judge ruled on Thursday that the government’s attempt to limit who can qualify for an exception to new Medicaid work requirements was illegal, while upholding other restrictions the government imposed.
The Centers for Medicare and Medicaid Services over the summer issued a final rule implementing work requirements for Medicaid coverage outlined in a 2025 law.
The rule limited who can qualify for one of the available exceptions beyond what was outlined in the law, including saying that people could only meet the “medically frail” exception if they have “an individual whose physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement.”
The policy also limited how states can verify eligibility for exceptions.
U.S. District Judge Richard Stearns in Massachusetts said in the ruling on Thursday that CMS lacked the authority to exclude any of the individuals defined as medically frail by Congress in the law. He ordered that part of the rule excised.
“It is well-recognized that there is an inherent public interest in ensuring that the government follows the law, and 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,” the judge wrote.
He also provided states a six-month stay of enforcement for determinations of whether individuals qualify as medically frail.
The new requirements are that individuals aged 19 to 64 must work, volunteer, or train for at least 80 hours each month, or attend school, to receive Medicaid coverage. Exceptions beyond being medically frail include being pregnant and being parents of children of certain ages.
CMS faces a Jan. 1, 2027, deadline for implementing the requirements.
The ruling came in response to a lawsuit from Democratic attorneys general.
Stearns did side with the government with regards to officials limiting the information states can use to verify eligibility for exceptions to 12 months prior, and restricts accepting self-attestations to once per enrollment period. He said states had not met the threshold to strike down those limits.
“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 said.
A CMS spokesperson said in an emailed statement that the agency does not comment on matters in pending litigation.
The American Medical Association welcomed the ruling.
“Today’s decision is a victory for patients as it strikes back against unnecessary barriers to care. 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,” Dr. Willie Underwood, president of the American Medical Association, wrote in an emailed statement.
“Patients should not have to clear unnecessary bureaucratic hurdles to keep their health coverage, especially hurdles that go beyond what Congress intended.”
