A coalition of Medicaid enrollees, prominent health care advocacy organizations, and the city of Columbus, Ohio, filed a lawsuit this week challenging the Trump administration's implementation of Medicaid work requirements, specifically targeting how the rule defines who qualifies as "medically frail." The suit, filed in federal court in Maryland, argues that the administration's final rule—issued in July—contravenes congressional intent by narrowly construing the medical frailty exclusion, thereby endangering coverage for individuals with severe physical and mental health conditions.
At issue is the One Big Beautiful Bill Act, which established work requirements for the Medicaid expansion population. Under the law, beneficiaries must work, volunteer, attend school part-time, or participate in job training for at least 80 hours per month. States are tasked with verifying compliance, but Congress carved out categorical exemptions for disabled individuals, those caring for young children, and people with serious health conditions—including the medically frail.
The plaintiffs contend that the administration's rule, which is set to take effect in January and will guide 42 states and the District of Columbia, improperly links the definition of medical frailty to a person's ability to work. To secure an exemption, individuals must prove that their condition prevented them from meeting the work requirement—a standard that advocates say is both burdensome and contrary to the statute's categorical exclusion.
"Congress created the medical frailty exclusion to protect people with serious health needs, but the administration's rule turns that protection into yet another obstacle people must overcome," said Jane Perkins, litigation director at the National Health Law Program, which is representing some of the plaintiffs alongside Democracy Forward. "The statute exempts the medically frail from work requirements and does not authorize CMS to re-introduce it through the backdoor with the new rule. This rule puts access to care and, in some cases, people's lives at risk."
The lawsuit asks the court to vacate the rule, alleging it is "arbitrary and capricious and contrary to law" and violates the Administrative Procedure Act. It is the latest in a series of legal challenges to the work requirements. In June, roughly two dozen states sued the Trump administration over the definition of "medically frail," and a federal judge in July declined to block the rule while that case proceeds.
GOP lawmakers and administration officials have defended the work requirements as a means to combat waste, fraud, and abuse in Medicaid. In recent guidance, the Centers for Medicare and Medicaid Services introduced a "tier system" aimed at reducing administrative burden for states. Under this framework, conditions would be categorized into tiers based on diagnostic coding and data sets. A Tier 1 condition would automatically qualify an individual for an exemption, while a Tier 2 condition would require additional evidence to demonstrate that the condition is severe enough to prevent work.
Critics argue that the tiered approach still forces chronically ill people to navigate a complex verification process, potentially leading to coverage losses. The outcome of this lawsuit could have sweeping implications for how states implement work requirements and for the health care of millions of low-income Americans. As the January implementation date approaches, the legal battle is likely to intensify, with advocates warning that the rule's narrow definition of medical frailty could leave many vulnerable individuals without access to care. The case also intersects with broader debates over Medicaid drug pricing and the administration's efforts to reshape the program through state-level deals.
