Five Medicaid enrollees, several national physician groups and the city of Columbus, Ohio, sued the federal government on Sept. 18, 2026, over how the new Medicaid work requirement treats people who are medically frail. The case, filed in federal court in Maryland, argues that a Centers for Medicare & Medicaid Services rule adds a hurdle Congress never wrote into the law. It lands ten days after CMS gave states a three-tier framework for deciding who qualifies, and a little more than three months before the requirement must be running nationwide on Jan. 1, 2027.
Who filed the Maryland lawsuit and what it asks
The case is Taylor et al. v. Kennedy Jr. et al., filed in the U.S. District Court for the District of Maryland. According to the American College of Physicians, the plaintiffs include five Medicaid enrollees from Kentucky, Illinois, Indiana, Missouri and North Carolina, along with the ACP, the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, Doctors for America, the New Hampshire Medical Society, the New Hampshire chapter of the American Academy of Pediatrics and the City of Columbus. The National Health Law Program and Democracy Forward represent them, joined by legal aid groups in Illinois, Missouri and Indiana.
The complaint targets the interim final rule CMS issued June 1. The 2025 budget law exempts people who are medically frail from the work requirement. The plaintiffs say the rule goes further by requiring people in covered categories to also show that their condition significantly impairs their ability to comply. Healthcare Dive reported that the suit seeks to stay that part of CMS policy.
“The statute does not require medically frail people to prove that their conditions are so debilitating that they cannot meet the work requirement,” Jane Perkins, litigation director at the National Health Law Program, said in a statement. The enrollees named in the case live with conditions including autism spectrum disorder, bipolar disorder, obsessive-compulsive disorder, severe vision impairment, HIV and narcolepsy, according to Stateline.
Exemptions still run through renewal paperwork. A medical frailty claim will be checked at application and at each renewal, so the dates and supporting documents matter as much as the diagnosis; the renewal document checklist in The SNAP & Medicaid Renewal Organizer keeps those items in one place.
The three-tier test CMS gave states on Sept. 8
On Sept. 8, CMS released guidance on implementing the medical frailty exclusion. It lists the groups that can qualify: people who are blind or disabled under Social Security Act rules, people with a substance use disorder, people with a disabling mental disorder, people with a physical, intellectual or developmental disability that significantly impedes one or more activities of daily living, and people with a serious or complex medical condition.
States may sort cases into three tiers using diagnosis codes and data such as fee-for-service claims, managed care encounters and health information exchanges, according to a summary by America’s Essential Hospitals. In Tier 1, available data is enough to confirm the condition significantly impairs a person’s ability to comply. In Tier 2, some data points to frailty but more information is needed. In Tier 3, there is little or no data, which triggers a manual, individual review that may call for medical history, treatment notes, discharge papers, medication lists, test results or a provider’s certification.
The guidance also covers self-attestation. Before Jan. 1, 2028, states may accept a person’s statement under penalty of perjury each time they check frailty status. After that date, a state may accept self-attestation only once per enrollment period. For substance use disorders, people in recovery for five or more years fall outside the category, and states may rely on claims adjudicated in the prior 12 months. The lawsuit argues that the 12-month look-back will screen out people who would qualify if states reviewed 24 months of data.
How the work requirement works for adults under 65
The underlying rule is unchanged while the case proceeds. CMS’s fact sheet says 43 states and the District of Columbia cover the affected population and must generally put the requirement in place no later than Jan. 1, 2027. It applies to non-pregnant adults ages 19 through 64 who are not entitled to or enrolled in Medicare and who get coverage through the Medicaid adult expansion group or certain section 1115 demonstrations.
Those adults must show 80 hours a month of work, community service, a work program or at least half-time school, or earnings of at least 80 times the federal minimum wage, which works out to $580 a month at the current $7.25 rate. States must verify compliance at application and renewal. When a state cannot verify it, the person gets 30 calendar days to show compliance or an exemption before an application can be denied or coverage ended.
People who are 65 or enrolled in Medicare are outside the requirement. The group most exposed to the frailty dispute is adults in their 50s and early 60s who have chronic illness but are not yet eligible for Medicare. For them, a lapse in Medicaid can mean missed prescriptions and specialist visits during the years just before retirement, when medical costs tend to rise and savings are often thin.
Earlier court fight and what comes next
This is not the first challenge to the frailty rules. Healthcare Dive reported that a federal judge in July rejected a bid by 25 states and the District of Columbia to pause the requirement over the same definition. The new case differs because enrollees and doctors are the plaintiffs. The physician groups argue that the rule pushes clinicians into judging whether patients can work. “As physicians, we are trained to diagnose and treat our patients’ medical conditions, not to conduct assessments about a given patient’s ability to work,” said Dr. Jan K. Carney, president of the ACP.
States are moving ahead in the meantime. Nebraska has already started its requirement, according to CMS. The National Disability Navigator Resource Collaborative reported on Sept. 18 that states are past the point when they had to begin outreach to enrollees, and pointed to growing renewal backlogs, longer call center waits and more procedural terminations in many states.
Unless a court acts, the Jan. 1, 2027 start date stands. Enrollees who believe they qualify for a frailty exclusion can check whether the state already has claims or provider documentation showing the condition, keep copies of recent treatment notes and medication lists, and answer any state request within the 30-day window. State contact information is listed on the Medicaid.gov beneficiary resources page.
A frailty exemption depends on paperwork arriving on time
Whatever the Maryland court decides, a person with a serious health condition will still have to answer state notices, supply medical documentation when data falls short and meet short response windows at each renewal.
The SNAP & Medicaid Renewal Organizer includes 51 state packs, a renewal document checklist and a renewal and reporting calendar, which help track state requests, treatment paperwork and renewal dates ahead of the Jan. 1 start.
Map out the next renewal with The SNAP & Medicaid Renewal Organizer.
This article was prepared with AI assistance and reviewed against the linked official sources.
