CMS Sued for ‘Medical Frailty’ Part of Medicaid Work Rules

In a new blog post, LeadingAge outlined the steps CMS is taking to provide resources and instructions to states to help states prepare to implement new Medicaid work reporting requirements. At the same time, a number of entities are suing the Trump Administration over the way people with “medical frailty” are treated in the new work requirements.

LeadingAge said a recent CMS webinar focused on the application of medical frailty exemptions and outlined optional steps states can take to verify medical frailty for exemption from work requirements, providing a three-tiered option as an available framework for establishing exemption.

“Agency staff also shared potential data sources and medical codes for consideration, as well as examples in an effort to help states understand their options and obligations,” the association said.

Slides from the presentation, distributed to states on Sept. 8, provide little new information, LeadingAge said.

“Examples show obvious examples of exemption eligibility within tiers and do not address the harder-to-determine grey areas. Additionally, the guidance provides no information to states about how claims data can actually demonstrate an individual’s ability to work, as was required by the interim final rule,” the blog post said.

More Options

During the call, LeadingAge said CMS outlined optional steps states can take to verify medical frailty for exemption from work requirements, providing a three-tiered option as an available framework for establishing exemption. CMS also shared potential data sources and medical codes for consideration, as well as examples in an effort to help states understand their options and obligations.

Work reporting requirements are applicable to the Medicaid Expansion population, those between 19 and 64, with income slightly over legacy eligibility requirements. The compliance deadline for states to implement the policy is Jan. 1, 2027.

“With the January 1 compliance date less than six months away, states are already communicating with enrollees to whom the new requirements apply. Pivoting to a new policy practice on medical frailty exemptions would add complexity to an already capacity-limited policy and timing challenge,” LeadingAge said.

States opting to accept self-declaration of exemption eligibility could find limited utility in the CMS presentation, with longer timelines to finalize exemption criteria prior to a concrete ex parte process by 2028.

Lawsuits Appear

A news article on Sept. 22 in The Hill newspaper said a new lawsuit is challenging how the Trump Administration plans to exempt medically frail people from Medicaid work requirements.

The report said Medicaid enrollees, alongside several major healthcare advocacy organizations and the city of Columbus, Ohio, said the final rule is not what Congress intended.

“They argue the rule narrowly defines who qualifies for the law’s medical frailty exclusion, putting people with serious physical and mental health conditions at risk of losing Medicaid because of new reporting and verification requirements, even though Congress categorically excluded medically frail people from the requirements,” the article said.

The coalition is asking a federal court in Maryland to vacate the rule, alleging it’s “arbitrary and capricious and contrary to law.” The suit also alleges violations of the Administrative Procedure Act, the law governing how regulations are issued.

The work requirement rule, issued in July, is meant to guide 42 states and the District of Columbia in carrying out the work rules implemented by the One Big Beautiful Bill Act.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.