A US federal court in Massachusetts held unlawful on Thursday the federal definition of “medically frail” in the Medicaid work requirements rule, vacated it and issued a permanent injunction, with a six-month stay.
Judge Stearns handed down the memorandum and order on cross-motions for summary judgment in Commonwealth of Massachusetts v Oz, civil action 26-12962-RGS. The court allowed in part and denied in part the states’ motion.
The stay, which the California attorney general’s office said was granted to accommodate any errors or delays from the changes to implementation, matters for timing. The opinion cites the short timeline in which the states must now change their verification systems.
The work requirement still begins on 1 January 2027. According to footnote 8 of the opinion, the states made clear at the hearing on 22 October that they did not seek to delay that implementation date.
The requirement comes from H.R. 1, signed on 4 July 2025, which makes Medicaid eligibility for “applicable individuals”, broadly the Affordable Care Act expansion population, contingent on a community engagement requirement. Under footnote 2, an applicable individual must perform 80 hours of work or community service each month. People who are medically frail or otherwise have special medical needs are excepted.
H.R. 1 required the health secretary to issue an interim final rule by 1 June. The rule, published on 3 June, was titled “Community Engagement Requirement for Certain Individuals”.
The states challenged three limitations: the incorporation of a work, study or community service requirement in the definition of “medically frail”; a limit on the age of information that may be considered, set at 12 months; and restrictions on the use of self-attestations. They pleaded claims under the Administrative Procedure Act and the Spending Clause.
The California attorney general’s office said the court held the administration’s definition of “medical frailty” contrary to law.
New Jersey’s attorney general said the court held that CMS lacked the authority to narrow the categories of medically frail individuals “by also requiring states to assess whether their condition significantly impairs their ability to work”.
The opinion records that the parties agree the term must “includ[e]” individuals who are blind or disabled, among the five subcategories Congress listed. The dispute concerned whether the agency could treat those categories as more than a floor.
The government’s cross-motion argued that it does not follow that “medically frail” “must include every possible object within” those subcategories. The court did not accept the agency’s definition.
The coalition filed suit on 29 June, led by the attorneys general of California, Massachusetts and New Jersey. Twenty-one other attorneys general joined, along with the governors of Kentucky and Pennsylvania.
The states said they had to notify Medicaid recipients of the changes by 31 August and could not wait for CMS to correct the rule through the continuing rulemaking process.
California attorney general Rob Bonta said:
“Today’s decision is a major victory that ensures that some of our most vulnerable residents are able to continue to access the healthcare they deserve.”
New Jersey attorney general Jennifer Davenport said: “This win will help people with complex or serious medical conditions stay on Medicaid and keep their healthcare.”
Her office said that, had the rule taken effect, many thousands of New Jersey residents would have lost access to care despite being eligible for Medicaid.