A federal judge in Boston has blocked the Trump administration from enforcing a stricter definition of 'medically frail' in Medicaid work requirement exemptions, ruling that the Centers for Medicare and Medicaid Services (CMS) exceeded its authority. U.S. District Judge Richard Stearns issued the decision on Oct. 29, 2026, siding with a coalition of 25 Democrat-led states and the District of Columbia in their lawsuit against the administration’s rule.
The ruling prevents CMS from imposing additional criteria on who qualifies for the 'medically frail' exemption, which the 2025 Medicaid law defines as including individuals with blindness, disabilities, substance use disorders, or serious medical conditions. The administration had sought to require that such individuals also demonstrate their conditions 'significantly impair' their ability to comply with work requirements, a standard not present in the original law.
Judge Stearns granted a six-month stay on enforcement of the stricter definition, allowing states time to adjust their eligibility verification systems. The decision does not invalidate the work requirements themselves, which mandate that Medicaid recipients aged 19 to 64 work, volunteer, or train for at least 80 hours per month unless exempt. Other exemptions remain in place, including for pregnant individuals and parents of young children.
Court Ruling: Key Details
The judge’s 16-page ruling emphasized the public interest in ensuring government compliance with the law. Stearns wrote that enforcing the unlawful definition could lead to the disenrollment of vulnerable individuals who rely on Medicaid for care. The plaintiffs, led by the coalition of states, argued that the stricter rule would disproportionately harm low-income Americans with chronic illnesses, forcing them to navigate burdensome verification processes.
CMS had issued the rule in summer 2026 as part of the 2025 'One Big Beautiful Bill', which authorized Medicaid work requirements. The administration’s guidance also limited how states could verify eligibility for exemptions, including rejecting certain forms of documentation. Stearns struck down this provision, stating that CMS lacked the authority to exclude individuals Congress explicitly defined as medically frail.
Policy Context: Work Requirements and Exemptions
Under the 2025 law, Medicaid recipients must meet community engagement requirements—such as employment, education, or volunteer work—to maintain coverage, unless they qualify for an exemption. The law’s definition of 'medically frail' includes:
- Individuals who are blind or disabled
- Those with substance use disorders or disabling mental health conditions
- People with disabilities that significantly impair daily activities
- Individuals with serious or complex medical conditions
The Trump administration’s rule sought to narrow this definition by requiring proof that a condition also impaired the individual’s ability to work. The judge ruled this went beyond the law’s text, violating the separation of powers by allowing CMS to rewrite statutory exemptions.
Reactions and Broader Implications
The ruling represents a partial victory for the coalition of states, which had sued the administration in June 2026 over the rule. While the decision eases access to exemptions for some Medicaid recipients, it does not challenge the work requirements themselves. The administration has not yet indicated whether it will appeal.
Health policy experts note that the ruling could have long-term effects on Medicaid administration, particularly as states grapple with verifying exemptions under the new framework. The case also highlights ongoing debates over work requirements in social safety-net programs, with critics arguing they create unnecessary barriers to care for vulnerable populations.
The Jan. 1, 2027 deadline for full implementation of the work requirements remains in place, though the administration may need to revise its guidance in light of the court’s decision.