A federal judge in Boston has thrown out the Trump administration’s rule that would have made sick and disabled Medicaid enrollees show their condition “significantly impairs” their ability to meet the program’s new work requirement before they could be exempted. U.S. District Judge Richard G. Stearns ruled October 29, 2026, that the Centers for Medicare & Medicaid Services had no authority to narrow the “medically frail” exemption Congress wrote, and he barred the agency from applying that test in Massachusetts and the other states that sued.
The states did not win everything. Stearns upheld two other limits they challenged, and the work requirement itself still begins January 1, 2027. We read the 16-page decision, the order of vacatur and the judgment on the court docket.
The case is Commonwealth of Massachusetts v. Oz, No. 1:26-cv-12962 (D. Mass.). Massachusetts is the first-named plaintiff in a group of 25 states and the District of Columbia. The defendants are CMS Director Mehmet Oz, CMS, Health and Human Services Secretary Robert F. Kennedy Jr. and HHS.
The work requirement and the exemption
- The law. The 2025 federal tax and spending law, which its sponsor called the “One Big Beautiful Bill,” makes Medicaid for “applicable individuals,” broadly the adults covered under the Affordable Care Act expansion, depend on “community engagement” starting January 1, 2027, the decision says.
- 80 hours a month. Under 42 U.S.C. § 1396a(xx), an enrollee meets the requirement in a month by working at least 80 hours, completing at least 80 hours of community service, participating in a work program for at least 80 hours, or enrolling in school at least half time, among other options. We read the section at Cornell’s Legal Information Institute.
- Who is exempt. The statute excludes an individual “who is medically frail or otherwise has special medical needs (as defined by the Secretary), including an individual” who is blind or disabled; has a substance use disorder; has a disabling mental disorder; has a physical, intellectual or developmental disability “that significantly impairs their ability to perform 1 or more activities of daily living”; or has “a serious or complex medical condition.”
- What CMS added. The interim final rule CMS issued in June 2026 defined a medically frail person as someone in one of those five groups “whose physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement,” the decision says.
What the judge decided
- The added test is unlawful. “Including,” Stearns wrote, introduces examples, so the five listed groups set “a definitional floor for the term ‘medically frail’ from which the agency lacked discretion to deviate.” He noted that Congress attached a functional limit to only one category, disability, and “clearly knew how to qualify classifications and did so where it wished.” The agency’s added requirement “is beyond the powers of CMS (ultra vires) and thus contrary to law.”
- The 12-month lookback stands. The rule lets states consider only claims and encounter data from the 12 months before an application to verify medical frailty.
- The one self-attestation limit stands. States may accept only one self-attestation of medical frailty per continuous period of enrollment.
- Why those two survived. “The court finds the States’ objections to the twelve-month lookback period and the limitation on the use of self-attestations unconvincing and falling well short of the arbitrary or capricious standard,” Stearns wrote. “That the States (or even the court) may disagree with the wisdom of the agency’s policies and conclusions, or may have made different choices, is irrelevant.”
The judge did not reach the states’ separate Spending Clause claim.
The orders
- Vacated. The “significantly impairs” language is “DECLARED unlawful, and VACATED and SET ASIDE pursuant to 5 U.S.C. § 706(2).”
- Injunction. CMS and anyone acting with it are enjoined from “implementing, enforcing, retroactively enforcing, or otherwise applying this provision to Plaintiff States.”
- Six-month grace period. CMS may not penalize the plaintiff states “for any errors or delays in implementing” the rule for six months from October 29.
- No delay of the start date. The states told the court they were not asking to push back the January 1, 2027, deadline, “a form of relief that the court in any event would be powerless to grant,” Stearns wrote.
- Judgment. Judgment entered for the states on Count I and partly for the government on Count II, and the case was closed.
On the harm, Stearns wrote that “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.”
What it means in Massachusetts
Massachusetts is a plaintiff, so the injunction covers MassHealth. For MassHealth members subject to the work requirement, a person who falls in one of the five categories Congress listed should not also have to show that the condition keeps them from meeting the 80-hour requirement. The 12-month limit on records and the single self-attestation rule still apply. How MassHealth will screen members is up to the state and federal agencies; the ruling does not set out a process.
The government can appeal to the U.S. Court of Appeals for the First Circuit. The docket showed no notice of appeal as of October 30. CMS, HHS and the White House did not respond to Stateline’s requests for comment Thursday. Dr. Willie Underwood, president of the American Medical Association, called the ruling “a victory for patients,” Stateline reported.
Frequently asked questions
Do Medicaid patients who are medically frail have to prove they can’t work?
Not in the states that sued, including Massachusetts. A federal judge vacated the part of the CMS rule that required a showing that the person’s condition significantly impairs their ability to meet the work requirement, and enjoined CMS from applying it to those states.
When do Medicaid work requirements start?
January 1, 2027, under the 2025 federal law. The ruling did not change that date.
Who counts as medically frail under the Medicaid work requirement?
The statute lists 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 one or more activities of daily living, or have a serious or complex medical condition.
What parts of the rule did the judge uphold?
The 12-month limit on the medical claims data states may use to verify medical frailty, and the limit of one self-attestation per continuous period of enrollment.
Sources: Memorandum and Order on Cross-Motions for Summary Judgment, Order of Vacatur and Enjoinment, and Judgment, Commonwealth of Massachusetts v. Oz, No. 1:26-cv-12962-RGS (D. Mass. Oct. 29, 2026), read in full on CourtListener; Stateline, October 29, 2026. 42 U.S.C. § 1396a(xx) read at Cornell’s Legal Information Institute. General information, not legal advice.