Federal District Court Vacates CMS’s “Medically Frail” Definition

A federal district court in Massachusetts on Oct. 29 vacated the Centers for Medicare & Medicaid Services' (CMS') definition of "medically frail." CMS defined this term in an interim final rule (IFR) implementing the community engagement requirements established in the Working Families Tax Cuts legislation (WFTCL).

Under the WFTCL, individuals with specified disabilities and serious or complex medical conditions qualify as "medically frail" and are exempt from the community engagement requirements. The IFR imposed an additional limitation: for an individual to qualify as "medically frail," the individual's disability or medical condition must "significantly [impair] the individual's ability to comply with the community engagement requirement."

The court held that CMS lacked the authority to impose the significant impairment requirement and therefore vacated and permanently enjoined the provision. The ruling applies nationwide. The court also granted states "a 6-month stay of enforcement as to any determination that an individual does or does not qualify as 'medically frail.'" The stay does not alter the Jan. 1, 2027, statutory effective date for the community engagement requirements.

Separately, the court rejected challenges to two other IFR provisions: the limitations on the use of self-attestations and the 12-month lookback period for information used to establish medical frailty.

As a result of the ruling, individuals who otherwise satisfy the statutory criteria for medical frailty will not be required to demonstrate that their disability or medical condition significantly impairs their ability to comply with the community engagement requirements. In addition, during the first six months of implementation (Jan. 1 to June 30, 2027), individuals cannot be removed from the Medicaid program if they claim the "medically frail" exception.

Contact Director of Policy Rob Nelb, MPH, at [email protected] or 202.585.0127 with questions.