A federal judge in Massachusetts struck down a key part of CMS’ “medically frail” definition for Medicaid work requirement exemptions on Oct. 29.
In June, 25 states and the District of Columbia sued the Trump administration over its interim final rule concerning Medicaid work requirements, which are set to go into effect Jan. 1. Under HR 1, many Medicaid expansion enrollees must work, go to school or volunteer to retain coverage.
The work requirements included an exemption for the “medically frail.” In its definition, Congress included people who are blind or disabled; have a substance use disorder; have a disabling mental disorder; have a physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or have a serious or complex medical condition.
But the crux of the lawsuit was how CMS added a parameter beyond what HR 1 outlined. CMS’ rule defined “medically frail” as someone whose condition “significantly impairs the individual’s ability to comply with the community engagement requirement” and who also falls into one of those five categories.
The judge ruled that CMS went beyond its authority by adding that requirement, saying the conditions Congress laid out should have served as a “floor” for the exemption. That “significantly impairs” piece in the interim final rule was vacated, and CMS is barred from applying it to the plaintiff states. These states will have six months to update their verification systems without being penalized for errors or delays tied to the “medically frail” definition.
Work requirements will still move forward according to the set timeline. The judge did not side with all of the states’ arguments. A 12-month lookback period for claims and encounter data used to verify frailty will still apply, as well as a limit on self-attestation.
“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,” American Medical Association President Willie Underwood III, MD, said in a statement. “Patients should not have to clear unnecessary bureaucratic hurdles to keep their health coverage, especially hurdles that go beyond what Congress intended. The AMA will continue fighting to protect access to medically necessary care and ensure bureaucratic red tape doesn’t stand in patients’ way.”
The states’ challenge is not isolated. In September, Medicaid beneficiaries and physician groups filed their own lawsuit targeting the work requirements. That is still ongoing.
CMS declined to comment.
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