What the Court’s Medical Frailty Ruling Means for Patients, Advocates, and the Future of Work Reporting Requirements

Medicaid work reporting requirements in the 2025 Republican budget law are engineered to push people off coverage, and the law's limited exemption guidelines are a thin line standing between people with chronic health conditions and disabilities and the loss of their care. CMS' June 2026 Interim Final Rule (IFR) tried to further strip away even those minimal protections by narrowing who could qualify for the "medical frailty" exemption and making it harder to document health conditions. On October 29, a federal court ruled in Massachusetts v. Oz that CMS illegally went beyond what this harmful law allows, rightly striking down the administration's overly limiting definition.

Good News: Court Sides with States on Definition of "Medically Frail"

In an attempt to stop the more restrictive rule from being implemented, a coalition of 25 states and the District of Columbia filed a lawsuit against the Trump administration challenging three provisions in the IFR related to the "medically frail" exemption for overstepping the authority they had under the law.

Congress explicitly exempted 5 categories of health conditions under the term "medically frail:" (1) blind or disabled, (2) substance use disorder, (3) disabling mental disorder, (4) physical, intellectual, or developmental disability that significantly impairs the person's ability to perform at least one activity of daily living, and (5) serious or complex medical condition. Under the CMS rule, it was no longer enough just to have one of those health conditions, but the Medicaid applicant or enrollee would also have to show that their condition was severe enough that it prevented them from working. The court declared this additional requirement unlawfuland struck it down nationwide. Further, the court order barred CMS from penalizing the 25 plaintiff states and D.C. for any errors or delays in implementing work reporting requirements through April 29, 2027. This enforcement delay gives these states more time to adjust verification systems to accommodate this change.

Bad News: Court Sides with CMS on Procedural Requirements for Identifying People Who Are "Medically Frail"

However, there were two other parts of the IFR that states challenged with which the court did not agree. The states also opposed 1) the CMS requirement that they could only use information from the past 12 months when verifying someone is medically frail, and 2) the rules limiting the use of self-attestation - a streamlined way for people to report a qualifying health condition without needing a provider to verify the information upfront. Unfortunately, the court said that these provisions in the IFR did not violate the law, and so these will remain.

What to Watch

The federal government is likely to appeal the ruling overturning the "medically frail" definition, and states could also appeal the portions of the court's ruling that uphold CMS' 12-month verification requirement and self-attestation limitations. States and advocates should expect a period of ongoing litigation and evolving CMS direction.

At the same time, another lawsuit on these issues, Taylor v. Kennedy, is also pending. The National Health Law Program and Democracy Forward brought this case against the Trump administration on behalf of Medicaid enrollees, health care provider associations, and a municipality. The parties are scheduled to submit motions and replies to the court over the next month.

What Can States and Health Advocates Do Now?

Advocates should use this decision and this opportunity to:

1. Encourage states to request good faith waivers from CMS to delay the start date of the new work reporting requirements. States now have a tight turnaround to make changes to their policies, systems, notices, and trainings to align with the court order. The likelihood of appeals and ongoing litigation are going to make implementation even more challenging. And if states get it wrong, they risk terminating Medicaid for eligible individuals who need access to ongoing care. Congress explicitly included this option for delays in the law, and states should take advantage of it.
2. Help develop comprehensive lists that include all conditions that fall into the "medically frail" categories in the law. States are required to have a list of diagnoses, conditions, and diseases that fall into this exemption. They will need to update these lists, which are likely too narrow now since they relied on the overly restrictive definition from CMS. The court was clear that CMS "lacked authority to exclude any subset of individuals" in the five medically frail categories in statute, so states and advocates should similarly ensure that they are not narrowing these categories by excluding any conditions that should count.
3. Push adoption of self-attestation to the greatest extent allowable under federal law and regulation, even though it is still limited. Self-attestation is particularly important for people who are newly applying to Medicaid or seeking treatment for the first time. States should not only adopt self-attestation as allowed but should also facilitate making it as easy as possible for people by adding user-friendly screening questions in the application and renewal form.
4. Adopt comprehensive lists of providers who can help verify someone is medically frail and make it easy for providers to confirm and submit this information. Recognizing that self-attestation and data lookback remains limited, it is that much more important for states to include all certified health professionals and reduce the burden on these providers when data matching is insufficient. For example, states should adopt simple, streamlined forms that allow all providers to check a box that someone has a medically frail condition, without requiring additional details or medical records.
5. Encourage states to adopt 12-month verification timeline for the medical frailty exemption. Now that there is no requirement that a person's health condition significantly impair their ability to work, it is even less likely that a person's medically frail status will change every six months when they need to renew their Medicaid. The IFR grants states the option to re-verify medical frailty every 12 months, instead of six, and states should adopt this approach to minimize the administrative burden on all parties involved and preserve access to health care.