Boston Judge Halts Strict Medicaid Frailty Proofs

A federal judge in Boston ruled on Thursday that chronically ill Medicaid recipients are not required to meet a heightened standard of proof to qualify for medical exemptions from new work requirements. The decision grants a partial win to a coalition of 25 states and the District of Columbia, which challenged the administration's interpretation of recent federal guidelines.

The legal dispute centers on the 2025 One Big Beautiful Bill, which mandates that Medicaid expansion enrollees aged 19 to 64 must work or perform community service for at least 80 hours per month, or remain in school at least half the time. The law allows exceptions for individuals deemed medically frail. However, Centers for Medicare and Medicaid Services guidance issued earlier this year required these individuals to demonstrate that their conditions significantly impair their ability to comply with the work mandates.

U.S. District Judge Richard Stearns blocked that specific requirement in a 16-page ruling. The court found that the stricter rule would force states to make costly and intensive alterations to their eligibility verification systems. Stearns noted that the states met their burden of showing irreparable harm, for which monetary damages would not provide adequate compensation. The judge stated that the government's concerns regarding disenrollment were not compelling enough to uphold that specific provision.

Morgan Henderson, an economist at The Hilltop Institute at the University of Maryland, Baltimore County, said the ruling will likely help preserve coverage for individuals who are sick but may not have met the previous documentation thresholds. He explained that those who would have lost coverage because they were not quite sick enough under the old rules might keep their benefits now. North Carolina Health and Human Services Secretary Dev Sangvai said in a statement that the decision allows the state to focus on delivering reliable care to vulnerable residents without the fear of losing coverage during treatment.

The ruling does not strike down the work requirements themselves. Stearns upheld two other federal restrictions on how states verify medical frailty. These include a rule requiring states to reject proof of frailty if the diagnosis is more than one year old, and a policy allowing states to accept only one self-attestation per continuous period of enrollment. Stearns explained that the government provided a non-frivolous rationale for adopting each of these provisions.

The change affects millions of lower-income adults covered through Medicaid expansion in most states. The new restrictions take effect on January 1, 2027. CMS declined to comment on the ruling. The lawsuit was filed in June by the coalition of states and the District of Columbia.